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Reference 


DENTAL   PKACTICB. 


NOTES 


ON 


DENTAL  PRACTICE. 


BY 


HENRY  C.  QUINBY, 

LICENTIATE    IN    DENTAL    SURGERY    OF    THE    ROYAL    COLLEGE    OF    SURIiBONS    IN 

IRELAND    AND    MEMBER    OF    THE    ODONTOLOGICAL    SOCIETIES 

OF    NEW    YORK    AND    LONDON. 


WITH  ILLISTRATIONS. 


PHILADELPHIA  : 

THE  S.  S.   WHITK  DENTAL  MANUFACTURING  CO. 

1884. 


PKEFACE. 


It  lias  not  been  my  purpose,  in  this  work,  to 
attempt  to  wade  in  the  deep  waters  of  physio- 
logical and  pathological  research.  I  am  content 
to  leave  the  elaboration  of  theories,  and  the 
search  after  causes,  in  the  able  hands  that  are 
now,  on  both  sides  of  the  Atlantic,  pursuing 
these  investigations  with  a  trained  skill  which 
cannot  fail  to  give  us  much  more  light  on  the 
now  hidden,  or  only  suspected,  sources  of  dental 
disease,  and  to  confine  myself,  as  strictly  as  a 
clear  explanation  of  my  meaning  will  permit,  to 
the  treatment  of  abnormal  conditions  of  the 
teeth. 

Dentists  may  well  be  proud  of  the  progress 
that  has  been  made  in  the  last  fifty  years, 
not  only  in  the  facilities  for  teaching,  but  in 
the  matter  taught,  in  dental  science.  Even 
twenty-five  years  ago  the  men  of  education  and 
social  position  in  our  profession  were  few  in 
number,    while    the    rank    and    file    were    looked 


VI  PREFACE. 

upon  as  mere  petty  tradesmen — deservedly  so — 
for  they  held  their  knowledge  as  a  collection 
of  trade  secrets,  to  be  jealously  guarded,  and 
handed  down  from  father  to  son  as  so  much 
stock-in-trade  ;  and  they  scarcely  dreamed  of 
the  possibility  of  improving  their  position,  and 
increasing  their  professional  knowledge  by  the 
free  interchange  of  thoughts  and  ideas  with  their 
fellow-practitioners.  The  dealer  in  dental  instru- 
ments and  materials  looked  upon  the  majority  of 
his  customers  as  his  inferiors  in  every  respect,  and 
if  he  listened  at  all  to  any  suggestions  for  im- 
proving his  wares,  it  was  with  the  indulgence 
and  condescension  of  one  who  was  quite  sure  he 
knew,  better  than  anybody  could  tell  him,  what 
a  dentist  needed,  and  that  what  he  considered 
proper  should  be  accepted  with  thankfulness. 
To  the  general  public  the  word  dentistry  meant 
tooth  pulling,  and  as  in  the  last  century  the 
barber  practised  blood-letting  and  called  himself 
a  surgeon,  so,  within  the  memory  of  many 
dentists,  the  chemist  has  considered  himself  a 
dental  practitioner  because  he  possessed  a  key 
for   extracting  teeth. 

But   a   brighter  prospect    for    dentistry   began 
to    open    in    the    second    quarter    of   the    nine- 


PREFACE.  Vll 

teenth  century.  Societies  were  organised  and 
meetings  held  for  the  discussion  of  professional 
subjects.  A  dental  hospital  was  established  in 
London,  and  the  example  was  soon  followed  in 
some  of  the  other  large  towns,  and  students 
were  admitted  to  see  the  operations.  A  College 
of  Dentistry  followed  naturally,  and  finally  the 
Dentists'  Act  of  1878  was  obtained  from  Parlia- 
ment by  the  sheer  persistency  of  a  few  of  our 
leading  men,  against  whom  every  possible  form 
of  discouragement  had  been  hurled.  But  this 
Act  gave  us  a  position  in  the  list  of  learned 
professions,  which  we  may  reasonably  hope  will 
continue  to  be,  as  it  has  been,  attractive  to 
men  of  education  and  natural  mechanical  ability. 
There  is,  however,  much  yet  to  be  learned ; 
and  the  teachings  of  experience,  as  well  as  the 
researches  of  trained  scientists,  being  valuable 
to  the  student,  it  becomes  the  duty  of  those 
who  have  seen  much  practice  to  make  its  lessons 
known  to  the  profession,  and  thus  add  as  much 
as  possible  to  the  available  knowledge.  This, 
therefore,  must  be  my  excuse  for  publishing 
these   notes. 


IX 


CONTENTS. 


CHAPTER   I. 
The   Temporary   Teeth        ...         ...         ...         ...  1 

CHAPTER   II. 
The  Permanent   Teeth       ...         ...         25 

CHAPTER  III. 

Extraction  as  a  means   of   Preventing  Decay...        59 

CHAPTER  IV. 
Irregularities  87 

CHAPTER   V. 
Treatment   of   Adult   Teeth        ...         ...         ...       114 

CHAPTER   VI. 
Amalgam  ...  ..         ...         ...         ...         ...       169 

CHAPTER  VII. 
Pivoting  ...         180 

CHAPTER   VIII. 
Gutta-Percha  for  Impressions     ...  ...         ...       192 


XI 


LIST   OF   ILLUSTRATIONS. 


Partially    developed    bicuspids    between    the    roots   of   the 

temporarj^  molars    ...         ...         ...         ...  6 

Bicuspids  in  malpositions,  which  may  be  caused  by  pre- 
mature extraction  of  the  temporary  molars;  four  illus- 
trations ...         ...         ...         ...         ...  7 

The  effect  upon  the  teeth   of  thumb-sucking  .  .         ...  21 

The  effect  upon  the   teeth   of  sucking  the   fingers  ...  22 

The   eflfect  upon  the   teeth   of  sucking  the  tongue  ...  23 

Gold  caps  for  gutta-percha  fillings  ;    three   illustrations  ...  32 

Wide  foramina  in  the  imperfectly  developed  roots  of  molar 

and  bicuspid 37 

Regulating-plate  for  moving  a  central  incisor  forward     ...  42 

Regulating-plate    for    turning    a    central,    and    moving    a 

lateral  incisor  forward        ..  ...         ...         ...         ...  .44 

Retaining-plate    for    holding    the    same    teeth    in    position 

imtil  the  new   alveoli  are  formed  ...         ...         ...  45 

A  good  mouth   mirror;   two   illustrations      48 

Manner  of  holding  the  mirror   while   operating     ...         ...  49 

Imperfect  and  interrupted    formation  of    enamel    on  front 

teeth;   four  illustrations ..      54,55 

Approximal  surfaces  of  teeth  cut   away  to  prevent  decay  57 

Upper  molar  elongated   so    as  to  prevent  the   closing  up 

of  gap   where  a  lower   molar  has   been   extracted   ...  61 

Prominent  upper  canines  65 

Second    bicuspids    extracted,    and   approximal    surfaces  of 

other   teeth   cut  away   to   prevent  decay         ...         ...  66 

Upper  and  lower  teeth  where   the    six   year  molars   have 

been  extracted  to  prevent   decay  ...  67 

Extracting    instruments  for  six  year   molars ;  seven  illus- 
trations ...         ...         ...         ...         ...         ...        71,   72,  7;^ 

Position    of    twelve    year    molars    and    wisdom    teeth    at 

different  periods       80 


Xll 

PAGE 

Upper  and  lower  teeth  of  a  boy  at  sixteen  years  of  age, 

the  six  year  molars  having  been   extracted    at  twelve 

to  prevent  decay      SI 

Effect  of   extracting    six    year   molars    on    one    side    and 

neglecting  to   do   so  on  the   other  side  84 

Upper  canine  erupted  in  a  wrong  position  at  twenty-three 

years  of   age,  and  moved  to  its   proper    place;    three 

illustrations 90,  91,  92 

Canine  and  bicuspid  out  of  position,  and  plate  for  correcting 

the  fault;   two  illustrations  93,  94 

Upper   front    teeth    projecting    and    lower    teeth    shutting 

against   the  palate  ...         ...         ...         ...         ...         ...  94 

Regulating-plate  to  cause  elongation   of  back  teeth        ...  9.5 

Treatment    of    projecting    upper    teeth    with    lower   teeth 

shutting  against  the  palate;  nine   illustrations 

96,  97,  98,  99,  100,  101,  102 
Treatment    of   projecting    upper    teeth,    with    lower    teeth 

of  normal  length;   six  illustrations  ...     102,  103,  104,  105,  106 
Faulty    articulation    and    treatment    showing    change    in 

form   of  upper  jaw;    four  illustrations  ...     107,  108,  109 

Use  of  jack  screws  in  regulating;  four  illustrations        ...109,  110 

Forms  of  regulating  plates;  five  illustrations        112,  113 

Use  of  the  mouth  mirror  in  operating         ...         119 

Various  shapes  of  chisels  and  excavators ;   two  illustrations  122,  123 
Loss  of  tooth  substance  from  erosion ;  three  illustrations  158,  159,  160 

Pivoting;   five  illustrations         181,  182,  185 

Pivoting,  retaining  one  cusp  of  a  bicuspid   and  restoring 

the    other:   four  illustrations 190,  191 


NOTES   ON   DENTAL    PRACTICE. 


CHAPTER  I. 

The    Temporary   Teeth. 

Although  the  dentist  may  not  often  be  called 
upon  to  watch  professionally  the  development  and 
eruption  of  the  temporary  teeth,  or  to  treat  the 
constitutional  disturbances  so  commonly  prevalent 
while  this  process  is  going  on,  he  cannot  fail  to 
take  an  interest  in  the  progress  of  first  dentition, 
and  his  skill  is,  unfortunately,  too  often  urgently 
needed  to  alleviate  pain  in  these  temporary  organs, 
long  before  they  are  removed  by  the  natural  process 
of  absorption,  to  make  room  for  their  permanent 
successors.  It  cannot  be  too  strongly  impressed 
upon  the  mind  of  the  student  in  dental  surgery 
that  the  preservation  of  the  milk  teeth,  and  their 
retention  in  the  mouth,  in  a  healthy  condition  if 
possible,  are  subjects  worthy  of  his  careful  atten- 
tion, and  of  the  greatest  importance  to  the  proper 
development  and  arrangement  of  the  permanent 
teeth.  And  when,  as  is  too  often  the  case  through 
neglect  and  inattention,  or  as  the  result  of  illness, 
these  teeth  become  a  source  of  pain  to  the  child, 
the  scientific  dentist  should  be  able  to  find  some 


]S  DENTAL    PEACTICE. 

method  to  relieve  the  sufferer  without  resorting  to 
the  only  treatment  which  was  possible  when  the 
blacksmith  and  the  barber  were  the  usual  operators. 
At  about  three  years  of  age  the  child  should 
have  all  the  temporary  teeth,  ten  in  each  jaw.  Mr. 
Tomes  fixes  the  average  age  for  the  completion  of 
first  dentition  at  forty  months.  And  it  is  our  duty, 
as  professional  men,  to  teach  those  who  have  the 
charge  of  children  that  the  mere  observation  of 
the  fact  that  twenty  teeth  have  appeared,  is  not 
all  that  is  needed.  These  teeth  should  be  cared  for 
from  the  first  moment  of  their  eruption.  The  brush 
must  be  used  for  the  child  until  the  little  one  is  well 
enough  to  be  trusted  to  use  it  efficiently.  The  teeth 
must  be  watched  to  see  that  they  are  not  becoming 
carious,  and  in  order  to  give  the  child  the  benefit  of 
professional  assistance  as  soon  as  possible,  should 
any  disease  appear,  and  before  it  should  have  time 
to  make  serious  progress.  It  is  an  advantage  to  the 
child  to  become  accustomed  to  having  the  mouth 
examined ;  to  be  made  to  feel  that  cleanliness 
there  is  as  essential  as  cleanliness  of  the  skin ;  to 
establish  a  habit  of  attention  to  the  teeth  as  early 
as  possible ;  and  to  have  the  mind  impressed  with 
the  idea  that  such  attention  is  of  the  greatest  im- 
portance to  health  and  comfort.  It  cannot  be 
supposed  that  a  child  of  two  or  three  years  of  age 
is  conscious  of  the  necessity  of  a  daily  bath  and 
frequent  washing  of  the  hands  and  face,  but  it 
submits  to  such  attentions  as  a  matter  of  obedience 
at   first,  and   constant  use  creates   the   habit,  and 


THE    TEMPORARY    TEETH.  3 

maintains  the  practice  after  mere  unreasoning  obedi- 
ence has  ceased  to  be  a  controlling  power;  thus 
bridging  over  the  period  between  the  performance  of 
the  act  in  obedience  to  authority,  and  the  continu- 
ance of  the  same  from  a  sense  of  duty  consequent 
upon  the  development  of  the  reasoning  powers. 

The  daily  use  of  the  tooth-brush  in  the  child's 
mouth  prevents  decay,  at  least  to  a  certain  extent ; 
but  it  does  much  more  than  this, — it  creates  a  want, 
a  feeling  that  neglecting  to  brush  the  teeth  is 
neglect  of  personal  cleanliness,  which  feeling,  if  it 
is  not  developed  in  early  childhood,  will  not  be 
developed  at  all,  or,  at  any  rate,  not  until  it  is  too 
late  for  the  teeth  to  have  the  advantage  of  care 
while  they  need  it  most. 

If  parents  themselves  are  unable  to  make  the 
needful  examination  of  the  child's  mouth,  the 
family  doctor,  or  the  dentist,  should  be  asked  to  do 
it ;  though  I  am  very  decidedly  of  opinion  that  the 
examinations  should,  at  least,  be  commenced  at 
home,  in  order  that  no  idea  of  fear  should  be  asso- 
ciated with  the  performance  of  this  duty.  Children 
wdll  learn,  much  more  readily,  to  take  the  needful 
care  of  their  teeth,  when  the  parents  show  a  real 
interest  in  teaching  them  to  do  so  ;  and  the  parents 
themselves  will  learn,  by  experience,  that  it  is  best 
to  avoid  the  absurd  practice  of  speaking  and  acting 
as  though  the  attentions  of  the  dentist  were  some- 
thing to  be  dreaded,  and  prepared  for  as  if  life  itself 
were  at  stake. 

As  the  child  is  taught  by  the  tone  of  home  con- 


4  DENTAL    PRACTICE. 

versation  to  expect  something  dreadful,  the  first 
work  of  the  dentist  is  to  correct  this  erroneous 
impression,  and  the  task  will  sometimes  tax  his 
patience  to  the  utmost  limit.  Possibly  two  or  three 
persons  will  accompany  the  child  on  the  first  visit 
to  the  dentist,  and  all  will  eagerly  unite  in  well- 
meant  assurances  of  the  harmless  intentions  of  the 
good  man,  who  only  wants  to  cure  baby's  pain, 
mingled  with  expressions  of  pity,  condolence,  and 
entreaties  for  brave  endurance,  the  only  effect  of 
which  is  to  make  the  child  feel  instinctively  that 
some  deception  is  intended,  and  naturally  to  in- 
crease its  terror. 

The  difficulty  is  the  want  of  knowledge  on  the 
part  of  the  parents  as  to  what  their  children's 
teeth  need.  Most  of  them  associate  only  one  idea 
with  a  visit  to  the  dentist,  and  it  is  therefore  the 
duty  of  the  latter  to  teach  while  he  practices ;  to 
endeavour  to  the  best  of  his  ability  to  correct  the 
false  ideas  of  the  parent  as  well  as  of  the  child ; 
and  to  learn  gentleness  and  patience  himself,  in 
order  to  make  his  teaching  the  more  effective. 

If  the  periodical  examinations  reveal  the  com- 
mencement of  decay  in  any  of  the  child's  teeth, 
prompt  measures  must  be  taken  to  stop  its  progress. 
Sometimes  this  can  be  done  by  cutting  away  the 
decay  with  chisel  and  file,  and  sometimes  by  fillings. 
A  sensible  discretion  on  the  part  of  the  dentist 
will  teach  him  what  should  be  done,  and  what 
should  be  left  alone.  The  time  the  teeth  are  to 
remain,  and  the   extent   and  probable  progress  of 


THE     TEMPORARY    TEETH.  0 

the  decay,  will  have  to  be  considered;  and,  generally, 
the  operations  should  be  attended  with  as  little 
pain  to  the  youthful  patient  as  the  necessities  of 
the  case  will  permit,  and  such  as  will  save  the 
teeth  as  long  as  nature  requires  their  presence  in 
the  mouth. 

Simple  fillings  of  some  of  the  preparations  of 
gutta-percha  will  be  effective  in  all  approximal 
cavities  that  cannot  be  cut  away  with  the  chisel,  and 
amalgam  will  serve  best  in  grinding  surface  cavities. 

I  have  seen  gold  used  for  this  purpose  in  tem- 
porary teeth,  but  the  practice  seems  to  me  some- 
thing worse  than  an  absurdity.  There  can  be  no 
possible  advantage  in  it.  The  difficulties  in  the  way 
of  making  good  gold  fillings  in  the  teeth  of  a  child 
of  such  tender  years  must,  indeed,  render  such 
work  less  effective  than  the  more  simple  fillings; 
and  the  operation  itself  is  far  too  trying  for  a  child, 
who  is  too  young  to  see  why  its  endurance  should 
be  so  exercised;  nor  should  the  operator  ever  forget 
the  danger  of  teaching  the  child  to  dread  a  visit  to 
his  surgery. 

Extraction  is  rarely  necessary  as  a  mere  cure 
for  pain,  and  should  never  be  resorted  to  when 
this  alone  is  the  object.  Probably  no  one  would  be 
satisfied  to  say  that  contraction  results  from  extrac- 
tion of  the  first  teeth,  and  that  therefore  extraction 
is  an  unjustifiable  interference  with  the  advance- 
ment of  the  second  teeth,  for  to  say  this  and  no 
more  would  be  to  form  a  very  inaccurate  idea  of 
what  takes  place.     Nevertheless,  there  is  coutrac- 


6 


DENTAL    PRACTICE. 


tion,  for  absorption  of  the  alveolus  follows  the 
extraction  of  the  first,  as  surely  as  it  does  that  of 
the  second  teeth,  and  I  have  seen  cases  where  the 
premature  loss  of  the  temporary  molars  caused  so 
much  shrinkage  of  the  gum,  that  one  would  almost 
feel  inclined  to  doubt  whether  the  bicuspids  had 
not  also  been  removed.  We  know  that  in  such 
cases  the  eruption  of  the  bicuspids  is  often  very 
much  delayed,  and  there   can  be  little  doubt  that 


^/T 


Figure  1. — Showing  the  partially  developed   bicuspids  between  the  roots 
of  the  temporary  molars. 

the  partially  developed  crown  of  the  bicuspid,  lying, 
as  it  does,  in  its  crypt,  between  the  spreading  roots 
of  the  temporary  molar— -(^S^e  Fig.  1) — may  often  be 
so  displaced  or  turned  in  its  position  in  the  dental 
arch,  by  the  wrenching  out  of  the  molar,  as  to  cause 
its  final  development  in  some  of  the  malpositions 
shown  in  Figs.  2,  3,  4  and  5. 


THE    TEMPORARY    TEETH. 


FigoreB  2,  3,  4  and  5. — Showing  the  bicuspids  in  malpositions  which  may 
be  caused  by  premature  extraction  of  the  temporary  molars. 


S  DENTAL    PRACTICE. 

We  know,  too,  that  it  takes  but  little  pressure  at 
this  early  age  to  change  the  position  of  a  tooth ; 
that  pressure  will  cause  absorption  of  the  alveolus 
on  the  side  of  the   tooth  opposite  to  which   it  is 
applied,  and  that  the  growth  of  the  maxillary  bones 
is  between   the   second   temporary  molar   and  the 
tuberosity  of  the  one,   and  the   second  temporary 
molar  and  the  ramus  of  the  other.     Therefore  we 
may  infer  that,  as  this  growth  is  dependent  upon  the 
formation  of  new  teeth  in  this  locality,  it  would  not 
take  place  if  room  were  made  for  the  teeth  to  de- 
velop in  space  already  provided.     If  we  extract  the 
second  temporary  molar  in  either  jaw   before  the 
development  of  the  permanent  molar  is  complete, 
there  is  nothing  to  prevent  the  permanent  molar 
from  occupying  that  space,    so   far  as   mere  space 
is  needed  for  the   completion   of  its  development. 
The  second  bicuspid  is   still  in  an   early  stage  of 
formation,   and  is  a  much  smaller  tooth  than  its 
predecessor,  so  that  it  cannot  act  as  a  barrier  to 
the  molar  moving  forward.      Thus  we  may  regard 
it  as  almost  a  certainty  that,  if  one  of  the  temporary 
molars  should   be   extracted  before  the  permanent 
ones  were  ready  to  be  erupted,  the  growth  of  the 
jaw  would  be  interrupted,  and  a  part  of  the  space 
reserved  for  the  ten  anterior  permanent  teeth  would 
be   occupied  by  one  that  should  have  found  space 
by  additional  growth. 

But  there  is  still  another,  and,  in  some  respects, 
a  worse  result  from  the  premature  extraction  of  the 
temporary   molars.      We   have  just    seen  that  the 


THE    TEMPORARY    TEETH.  9 

roots  of  the  temporary  molars  diverge  very  much  to 
make  room  for  the  development  of  the  bicuspids, 
therefore  the  extraction  of  a  tooth  so  formed  must 
of  necessity  be  a  very  painful  operation.  It  is  not 
an  uncommon  thing  for  a  bicuspid  to  be  so  much 
smaller  than  the  molar  that  it  will  not  occupy  all 
the  space  between  these  wide- spreading  roots,  and 
in  such  a  case  the  roots  of  the  molar  may  not  be 
equally  affected  by  the  process  of  absorption,  so  that 
the  bicuspid  will  be  diverted  from  its  position,  and 
we  are  obliged  to  extract  the  molar  before  one  or 
more  of  the  roots  are  completely  absorbed.  We 
can  then  judge  how  much  more  painful  and  diffi- 
cult the  extraction  of  such  a  tooth  would  be  when 
its  roots  are  in  perfect  development,  than  the 
extraction  of  a  permanent  molar.  Yet  a  child  of 
tender  years  is  to  be  subjected  to  this  operation, 
because  it  is  the  quickest  way  to  cure  a  toothache. 
The  inevitable  result  must  be  to  create,  in  the  mind 
of  the  child,  that  dread  of  the  very  name  of  a  dentist 
which  is  the  greatest  stumbling-block  in  the  way  of 
what  should  be  our  chief  work — the  prevention  of 
pain  by  seasonable  operations.  Is  it  reasonable  to 
suppose  that  a  child  will  come  willingly  to  us,  after 
such  an  operation,  to  have  something  done  to  a 
tooth  which  has  been  painless  hitherto  ?  The 
dentist  cannot  be  too  careful  to  avoid  causing  this 
fear  of  his  work,  and  although  operations  may  be 
needful,  it  is  better  sometimes  to  win  the  confidence 
of  the  child  on  the  occasion  of  a  first  visit  by  doing 
nothing,  or  only  some  slight  operation  that  will  not 


10  DENTAL   PRACTICE. 

give  pain,  than  to  terrify  the  young  patient  by  pain- 
ful work,  and  thus  effectually  banish  it  from  the 
consulting  room,  until  dire  extremity  of  suffering 
shall  force  a  visit. 

One  would  scarcely  say  that  premature  extrac- 
tion of  the  temporary  teeth  is  never  necessary  ;  but 
in  the  course  of  an  extensive  practice  for  more  than 
a  quarter  of  a  century,  I  have  never  met  with  a  case 
where  I  considered  it  necessary.  As  I  have  before 
remarked,  it  is  far  from  being  an  uncommon 
occurrence  to  have  these  small  patients  brought  to 
us  with  aching  teeth,  but  I  believe  these  cases  may 
always  be  treated  without  resort  to  extraction. 

Toothache  is  a  symptom,  not  a  disease ;  and  it 
may  proceed  from  a  variety  of  causes,  which,  how- 
ever, rarely  affect  the  temporary  teeth  ;  so  that  it 
will  be  sufficient  for  the  present  to  confine  our 
attention  to  the  two  most  easily  recognised  causes 
of  this  pain,  viz.,  inflammation  of  the  pulp,  and  of 
the  lining  membrane  of  the  socket.  When  a  child 
is  brought  to  us  suffering  from  toothache,  our  first 
enquiries  should  be  to  ascertain  which  of  these  two 
causes  is  responsible  for  the  pain.  If  it  is  due  to 
inflammation  of  the  pulp,  the  pain  may  not  be  felt 
at  all  in  the  tooth  from  which  it  actually  proceeds, 
but  in  any  of  the  numerous  branches  of  the  fifth 
nerve,  or,  even  more  remotely,  through  the  connec- 
tions of  the  fifth  with  the  great  sympathetic  nerve. 
More  generally,  however,  the  source  of  pain  may  be 
localised  to  this  extent,  that  if  the  pain  is  caused  by 
an  inflamed  pulp  in  an  upper  tooth,  it  will  be  felt  in 


THE    TEMPORARY    TEETH.  11 

some  of  the  branches  of  the  superior  maxillary 
nerve  ;  while  if  it  proceeds  from  a  lower  tooth,  the 
sensation  is  felt  in  some  of  the  branches  of  the 
inferior  maxillary  nerve.  Though  this  is  never 
absolutely  reliable,  it  is  sufficiently  so  to  be  of  great 
use  in  determining  the  source  of  facial  pain.  If 
the  pain  is  caused  by  inflammation  of  the  lining 
membrane  of  the  socket,  there  will  be  little,  if  any, 
difficulty  in  the  diagnosis.  The  tooth  is  sensitive 
to  pressure  in  the  early  stages,  and  this  steadily 
increases  until  an  abscess  is  developed,  when,  of 
course,  there  cannot  be  any  doubt  as  to  the  source 
of  pain.  Thus,  if  there  are  several  decayed  teeth 
on  the  painful  side,  a  few  simple  questions  will  be 
of  great  service  in  helping  us  to  decide  which  one  is 
the  cause  of  pain.  We  must  not  trust  too  much  to 
the  patient  when  we  have  reason  to  suspect  an 
inflamed  nerve,  for  the  sufferer  is  more  likely  to 
point  out  the  wrong  tooth  than  the  right  one.  We 
must  rather  trust  our  own  judgment  in  these  cases, 
and,  when  we  are  satisfied  as  to  the  cause  of  pain, 
the  treatment  is  easy. 

If  there  be  inflammation  and  congestion  of  the 
socket,  a  free  opening  into  the  pulp  cavity  will 
almost  invariably  give  instant  relief.  Syringing 
out  the  cavity  with  warm  water,  and,  perhaps,  if  the 
tooth  is  not  too  sore,  cutting  away  the  decayed 
parts,  so  as  to  make  the  cavity  self-cleansing,  will 
be  all  that  can  be  done  in  a  case  of  this  nature.  In 
the  majority  of  cases  it  is  best  to  defer  the  cutting 
and   shaping  of  the  cavity  until  the  soreness  sub- 


12  DENTAL    PRACTICE. 

sides,  which,  we  may  be  quite  sure,  will  quickly 
take  place  after  the  putrescent  pulp  has  been 
removed  by  the  syringing. 

When  the  pain  is  caused  by  an  inflamed  pulp, 
the  course  of  treatment  is  different,  and  we  cannot 
always  expect  such  speedy  relief  from  the  suffering. 
Having  satisfied  ourselves  that  inflammation  of  the 
pulp  is  the  cause  of  pain,  we  first  gently  remove, 
with  a  sharp  excavator,  the  carious  bone  that  covers 
the  pulp,  until  we  can  see  the  nerve.  Quite  possibly 
we  may  not  be  able  to  go  so  far  as  this  without 
causing  a  great  deal  of  pain,  but  with  a  sharp 
instrument  it  can  usually  be  done,  and  it  is  better 
to  do  it,  if  possible,  because  the  patient  is  less 
likely  to  suffer  afterwards,  if  the  nerve  is  fairly 
uncovered  and  bleeding ;  but  this  should  not  be 
insisted  on  too  strongly,  as  a  little  pain  after 
leaving  the  dentist's  chair  is  not  so  likely  to  intimi- 
date the  patient  for  the  future,  as  pain  that,  to  the 
child,   seems  needlessly  inflicted  by   the  operator. 

If  the  nerve  is  wounded  so  as  to  cause  a  flow  of 
blood  from  the  congested  vessels,  there  will  be  pain 
while  the  blood  is  flowing,  but  the  nerve  will  be  all 
the  more  readily  acted  upon  by  the  devitalizing 
dressing  which  we  are  about  to  apply,  and  if  it 
is  anything  more  than  momentary  pain,  a  little 
carbolic  acid  on  a  pledget  of  cotton  or  a  bit  of 
amadou,  applied  to  the  bleeding  surface,  will 
quickly  allay  the  pain.  The  dressing  for  destroying 
the  nerve  should  be  a  mixture  of  arsenious  acid  and 
sulphate  of  morphia,   in   equal   parts,  and  ground 


THE    TEMPORARY    TEETH.  13 

in  a  mortar  until  it  is  a  perfectly  impalpable 
powder.  Four  hours'  grinding  for  an  ounce  of  the 
mixture  is  not  too  much,  as  the  action  upon  the 
nerve  being  so  much  more  certain  when  the  mix- 
ture is  finely  triturated,  it  will  well  repay  the  extra 
trouble ;  which,  however,  is  not  much  when  we 
consider  that  an  ounce  ought  to  be  sufficient  to 
destroy  the  nerves  of  ten  thousand  teeth ;  quite  as 
many,  probably,  as  will  be  presented  for  treatment 
in  a  lifetime  of  active  practice.  Arsenic  alone  is 
said  to  cause  great  pain,  which  morphia  is  used  to 
prevent.  The  latter  certainly  reduces  the  strength 
of  the  arsenic  by  one-half,  and  as  I  have  been 
satisfied  with  the  action  of  the  mixture  in  this 
form,  I  have  never  been  tempted  to  try  a  change  of 
proportions.  The  best  method  of  using  it,  accord- 
ing to  my  experience,  is  to  roll  up  tightly  in  the 
fingers  a  pledget  of  cotton  about  the  size  of  an 
ordinary  pin's  head  ;  moisten  this  with  carbolic 
acid,  but  not  to  saturation,  and  then  gently  touch- 
ing the  pledget  to  some  of  the  powder,  a  sufficient 
quantity  will  be  taken  up  to  serve  the  purpose  ; 
it  should  be  placed  directly  on  the  nerve,  and 
covered  up  with  a  larger  pledget  of  cotton,  sufficient 
to  till  the  cavity,  and  some  stiff  sandarac  varnish 
mingled  with  the  fibre.  This  will  efi'ectually  prevent 
the  escape  of  any  of  the  arsenic,  even  if  the  dressing 
is  left  for  a  week  in  the  tooth ;  but  great  care  must 
be  taken  in  all  cases,  and  especially  in  approximal  or 
buccal  cavities  near  the  gum,  to  avoid  leaving  even 
the  most  minute    quantity    of  the   powder  on  the 


14  DENTAL    PEACTICE. 

gum,  and  to  prevent  its  escape  from  the  cavity  after 
it  is  placed  in  position,  as  death,  of  the  part  and 
sloughing-  will  inevitably  result  from  such  clumsy 
manipulation.  The  use  of  such  powerful  drugs  is 
only  safe  when  neatness  and  carefulness  are  instinc- 
tive with  the  operator ;  but  clumsiness  ought  never 
to  be  associated  with  the  practice  of  dentistry.  On 
grinding  surfaces,  where  the  edges  are  broken  down 
so  that  there  is  very  little  depth  of  cavity,  it  is 
sometimes  better  to  cover  the  arsenical  dressing 
with  plaster  of  paris,  as  this  will  adhere  to  the 
dentine  better  than  the  sandarac.  The  plaster 
should  be  mixed  with  hot  water,  and  a  few  fibres  of 
cotton  may  be  mingled  with  it  to  give  it  more 
strength.  If  the  dressing  is  quite  secure  in  the 
tooth,  it  cannot  do  any  harm  to  let  it  remain  for 
a  week  ;  but  if  it  is  not  very^  secure,  owing  to  the 
form  of  the  cavity,  it  may  be  removed  in  twelve  or 
twenty-four  hours.  In  any  case,  however,  the  tooth 
should  be  seen  again  in  about  a  week  or  ten  days, 
and  then  the  pulp  cavity  should  be  thoroughly  laid 
open,  and  all  broken  rough  edges  of  the  tooth  cut 
away  in  order  to  facilitate  cleanliness,  and  prevent 
as  much  as  possible  the  lodgment  of  food,  for  the 
tooth  must  be  left  without  a  stopping.  It  cannot  be 
treated  as  we  should  treat  those  of  a  later  period, 
by  removing  the  pulp  and  filling  the  roots,  unless 
we  are  quite  sure  that  there  has  not  been  any 
absorption  of  the  roots  to  widen  the  apical 
foramina,  and  thus  render  a  tight  filling  impos- 
sible.    Mr.  Tomes  tells  us  that  the  roots  of  some  of 


THE    TEMPORARY    TEETH.  15 

these  teeth  are  not  fully  developed  until  the  child  is 
four  and  a  half  years  of  age ;  we  may  therefore  be 
quite  sure  that  the  period  of  time  t)etween  perfect 
formation  and  the  commencement  of  absorption  is 
very  limited,  so  that,  practically,  we  may  say  it  does 
not  exist  for  the  success  of  this  operation.  It  is 
better,  therefore,  to  leave  the  tooth  without  a  filling, 
but  so  shaped  that  lodgments  of  food  may  be  easily 
removed,  and  the  neighbouring  teeth  suffer  no 
injury.  What  remains  of  the  pulp  will,  of  course, 
pass  through  the  stages  of  putrescence  and  slough- 
ing, but  if  the  gases  have  free  escape  into  the  oral 
cavity,  there  will  be  very  slight  risk  of  their  causing 
what  may  be  called  secondary  toothache,  or  inflam- 
mation of  the  lining  membrane  of  the  socket,  which 
is  simply  the  result  of  the  poisonous  action  of  the 
gases,  generated  by  decomposition  of  the  pulp,  in 
a  cavity  which  has  no  outlet,  except  the  apical 
foramen.  We  may  be  very  sure  that,  if  the  pulp 
cavity  is  well  opened,  and  kej)t  open,  these  gases 
will  escape  harmlessly  by  the  larger  opening,  rather 
than  by  the  smaller  one  at  the  end  of  the  root. 

I  am  perfectly  well  aware  that,  to  some  of  the 
members  of  our  profession,  who  would  probably  call 
themselves  purists,  if  they  could  choose  a  distinc- 
tive designation  for  themselves,  this  treatment  of 
pulps  may  seem  dreadfully  heterodox,  but  I  should 
be  glad  to  hear  of  one  well- authenticated  case  where 
the  pulp  of  a  temporary  tooth  in  the  mouth  of  a 
child  under  six  years  of  age  has  been  capped  and 
preserved    alive,   or   where    the    nerve    has    been 


16  DENTAL    PRACTICE.  ^ 

removed  and  the  roots  filled,  so  as  to  prevent 
alveolar  abscess.  And  if  abscess  does  occur,  what 
is  to  be  done  ?  It  is  absurd  to  talk  of  taking  root 
fillings  out  of  a  tooth  that  is  painful  from  this  cause, 
when  the  patient  is  not  old  enough  to  fully  appre- 
ciate the  advantage  of  retaining  a  valuable  tooth, 
knowing,  as  we  all  probably  do,  how  extremely  difii- 
cult  it  is  to  remove  root  fillings,  under  similar  cir- 
cumstances, from  adult  teeth.  It  is  quite  as  much 
as  we  can  do  to  persuade  a  child  suffering  from 
abscess  to  allow  us  to  open  the  pulp  cavity  and 
syringe  it  out,  although  we  know  that,  in  such 
cases,  relief  from  pain  follows  so  quickly  that  we  can 
be  quite  sure  of  sending  the  little  patient  away 
happy  and  comfortable ;  but  if  the  roots  were  filled, 
there  would  be  very  little  chance  of  relief  to  the 
sufferer  until  the  abscess  had  run  its  course,  or  the 
tooth  had  been  removed.  It  is  a  choice  of  evils,  but 
I  maintain  that  less  harm  will  be  done  by  leaving 
such  a  tooth  in  the  mouth,  and,  of  course,  keeping 
it  clean,  than  will  be  done  by  extracting  it,  although 
I  have  very  little  doubt  in  my  own  mind  that  the 
death  of  the  pulp  very  greatly  interferes  with,  if  it 
does  not  altogether  put  a  stop  to,  the  natural 
absorption  of  the  roots.  This  is  a  point  which  I  do 
not  think  has  been  noticed  hitherto  by  any  author, 
but  if  it  is  not  so,  why  do  we  always  find  the  roots 
of  dead  temporary  molars  pushed  aside  by  the 
advancing  bicuspids,  so  that  we  often  have  to  ex- 
tract long  thin  splinters  of  roots  from  around  the 
new  tooth  ?     These  roots  may  certainly  be  said  to 


THE    TEMPORARY    TEETH.  17 

have  served  to  guide  the  new  tooth  into  its  proper 
position,  but  they  never  show  any  traces  of  recent 
absorption.  There  is  no  appearance  resembling  the 
absorbent  organ — nothing  different  from  what  we 
should  see  if  the  dead  root  of  a  permanent  tooth 
were  left  in  the  mouth.  On  the  other  hand,  if  the 
temporary  tooth  has  remained  perfectly  healthy, 
we  shall  almost  always  find  the  roots  completely 
absorbed,  and  the  absorbent  organ  occupying  the 
place  of  what  was  the  pulp.  It  may  be  argued  that, 
if  this  is  the  case,  it  must  be  better  to  extract  than 
to  leave  roots  which  will  be  obstructive  in  their 
relation  to  the  permanent  tooth.  But  I  contend 
that  we  do  not  leave  an  obstruction  in  the  way  of 
the  permanent  tooth.  After  the  death  of  the  pulp 
and  the  opening  of  the  pulp-cavity,  the  remainder 
of  the  crown  of  the  tooth  will  rapidly  disappear, 
and  practically  there  will  be  nothing  but  the  roots 
left  to  be  displaced  by  the  advancing  tooth.  And 
these  do  not  prove  to  be  an  obstruction,  for  they  are 
simply  pushed  aside,  and  the  new  tooth  comes  into 
its  right  position  almost,  if  not  quite,  as  quickly  as 
it  would  have  done  if  its  predecessor  had  been 
perfectly  healthy  ;  but  if  the  temporary  tooth  is 
extracted,  we  know  that  the  permanent  one  is  often 
very  much  delayed  and  misplaced. 

It  will  often  happen  that  a  child  will  not  be 
taken  to  the  dentist,  although  really  suffering  from 
primary  toothache,  because  the  parents  are  not 
aware  of  the  cause  of  the  pain.  The  child  does  not 
feel  the  pain  in  a  tooth,  but  rather  in  the  temple,  or 

B 


18  DENTAL    PRACTICE. 

in  the  ear.  It  is  well  enough  all  day,  perhaps,  and 
takes  its  food  as  usual,  but  cries  with  pain  all  night 
from  genuine  toothache,  although,  perhaps,  there 
may  be  no  disagreeable  sensation  in  the  tooth 
which  causes  the  pain. 

The  pulp  will  not,  however,  long  survive  a  con- 
dition of  acute  inflammation,  and  with  its  death  the 
pain  disappears  and  is  forgotten.  But  there  is  left 
in  the  tooth  a  fleshy  substance,  which  was  lately 
nerve  and  blood-vessels,  and  this  having  died  a 
natural  death,  will  in  time  become  putrid.  It  is  not 
necessary  here  to  attempt  to  explain  the  nature  of 
putrescence,  for  it  is  well  known  in  the  profession, 
that  one  of  our  most  scientific  men,  Mr.  Charles 
Tomes,  with  his  able  associates  in  physiological 
research,  is  at  the  present  time  investigating  the 
subject  of  the  agency  of  bacteria  in  the  develop- 
ment of  alveolar  abscess,  and  we  may  be  quite  sure 
that  the  work  will  be  well  done.  But  we  know  that 
the  pulp  of  a  tooth,  which  is  so  shut  up  in  the  tooth 
that  the  gases  generated  by  decomposition  have  no 
vent  except  through  the  apical  foramina,  so  that  it 
would  appear  as  though  putrescence  could  not  be 
the  effect  of  external  causes,  may  and  does  become 
putrid,  and  generates  poisonous  gases  which,  having 
no  direct  means  of  escape  into  the  oral  cavity 
through  the  partially  only  disintegrated  dentine, 
that  is  yet  sufficiently  decayed  to  have  affected 
and  caused  the  death  of  the  pulp,  will  find  their  way 
through  the  foramen  by  which,  while  the  vessels 
were  in  health,  the  blood  found  access  to  the  tooth, 


THE    TEMPORARY    TEETH.  19 

and  will  so  poison  the  surrounding  tissues  that 
inflammation,  and  perhaps  abscess,  will  result.  This 
is  what  I  have  called  secondary  toothache,  and  it  is 
what  the  sufferer  never  mistakes  for  anything  but 
toothache,  and  can  always  localise  without  any 
hesitation,  because  the  pain  is  directly  intensified 
by  pressure  on  the  tooth,  so  that,  in  these  cases, 
the  patient's  judgment  is  of  great  use  in  helping  the 
dentist  to  decide  where  his  skill  is  needed  to  relieve 
pain. 

The  treatment  of  this  form  of  toothache  may 
have  been  sufficiently  indicated  in  the  previous 
pages,  but  it  deserves  special  and  definite  men- 
tion. It  is  simply  the  free  opening  of  the  pulp 
c^ity,  the  removal  of  all  putrescent  matter, 
for  which  purpose  fine  barbed  instruments,  that 
will  reach  well  into  the  roots,  will  be  required ; 
syringing  with  warm  water  to  which  a  five  per 
cent,  proportion  of  carbolic  acid  may  be  added ; 
and,  when  it  can  be  done  without  risk  to  the 
adjacent  parts,  a  drop  of  the  acid  of  full  officinal 
strength  may  be  left  in  the  tooth.  But  this  is  only 
possible  in  lower  teeth,  because  there  must  not  be 
any  stopping  inserted,  not  even  of  cotton,  at  this 
stage  of  the  treatment,  to  prevent  the  free  escape  of 
gases  or  pus  through  the  pulp  canals.  The  relipf 
from  pain  will  be  almost  instantaneous.  A  certain 
amount  of  soreness  will  remain,  but  the  intensity  of 
the  suffering  will  be  gone,  as  if  by  magic,  and  the 
soreness  will  disappear  as  surely,  though  more 
gradually ;  and  we   may  with  confidence  make  an 


20  DENTAL    PRACTICE. 

appointment  for  the  child  to  be  brought  back  to  us 
in  three  or  four  days,  when  the  tooth  will  bear 
pressure  without  giving  pain.  We  should  then  so 
shape  what  remains  of  the  tooth,  that  it  can  be 
easily  kept  clean,  and  we  should  endeavour  to 
impress  upon  the  minds  of  those  in  charge  of  the 
child  the  necessity  of  cleanliness,  if  they  would 
avoid  a  repetition  of  the  suffering. 

Irregularity  in  the  position  or  occlusion  of  the 
temporary  teeth  is  not  of  sufficient  importance  to 
justify  interference,  unless  it  is  caused  by  the 
infantile  habit  of  sucking  the  thumb,  the  fingers, 
the  lip,  or  the  tongue — practices  which,  if  per- 
severed in,  as  they  undoubtedly  are  by  some 
children,  even  after  the  tempora-ry  teeth  have  all 
disappeared,  may  be  the  cause  of  serious  displace- 
ment of  the  permanent  teeth,  with  malformation  of 
the  jaws.  Some  of  the  most  troublesome  irregu- 
larities we  have  to  treat  are  traceable  to  this  habit 
of  sucking,  and  the  dentist  should,  in  all  cases  that 
come  under  his  observation,  see  how  the  teeth 
close,  and,  if  there  is  any  fault  in  this  respect,  it 
should  be  pointed  out  to  the  parents,  and  the 
necessity  for  breaking  up  a  habit  so  liable  to  cause 
disfigurement  should  be  strongly  urged. 

It  will  be  seen  at  once  that  the  weight  of  the 
hand,  when  the  thumb  is  constantly  in  the  child's 
mouth,  will  have  the  effect  of  shortening  the  lower 
jaw  and  elongating  the  upper.  The  lower  front 
teeth  will  have  an  inward  inclination,  showing  a 
straight  or  even  concave  line  from  one  canine  to  the 


THE    TEMPORARY    TEETH. 


other,  while  the  upper  teeth  will  project  over  the 
lower  Hp. 


Figure  6. — Showing  bow  thumb  sucking  may  effect  the  arrangement  of  the 

front  teeth. 

Fig.  6  is  a  remarkably  good  illustration  of  the 
effect  of  this  habit,  which,  in  this  case,  was  con- 
tinued until  the  child  was  twelve  years  of  age.  Two 
of  the  lower  bicuspids,  as  will  be  seen,  have  been 
extracted  by  some  one  who  probably  thought  he 
had  a  reason  for  such  treatment;  but  I  cannot 
believe  that  they  were  so  much  out  of  place  that 
they  could  not  have  been  pressed  into  position, 
which  would  certainly  have  been  better  than  remov- 
ing them,  as  the  effect  of  forcing  them  into  their 
proper  place  must,  of  necessity,  lengthen  the  lower 
jaw  to  something  nearer  what  it  should  be.  Like 
many  other  cases,  this  is  one  where  more  thought 
for  the  future  of  the  mouth,  and  a  little  more 
trouble  in  regulating  the  teeth,  instead  of  extracting 
those  that  may  be  out  of  place,  would  be  much 
more  creditable  to  us  as  professional  men. 

Sucking  the  fingers  will  have  a  different  effect 
upon  the  development  of  the  mouth.  There  is  no 
leverage  upon  the  upper  teeth,  but  the  weight  of  the 


22  DENTAL    PRACTICE. 

hand  acts  directly  to  elongate  the  lower  maxillary, 
causing  what  is  usually  described  as  an  ''  under- 
hung jaw."     Fig.  7  is  an  example  of  this. 


Figure  7. — Showing  the  effect  that  may  be  produced  upon  the  lower  jaw  by 
sucking  the  fingers. 

Sucking  the  lower  lip  produces  a  result  some- 
what similar  to  that  caused  by  thumb-sucking,  and 
sucking  the  tongue  may  seriously  displace  the 
canine  and  bicuspids  of  one  side  of  the  mouth,  as 
the  child  will  usually  turn  the  tongue  to  one  side  or 
the  other,  and  always  to  the  same  side.  Fig.  8 
represents  the  worst  case  I  have  ever  seen  of  the 
effect  of  sucking  the  tongue.  The  boy  was  eight 
years  of  age  when  I  first  saw  him.  His  intellectual 
development  was  below  the  average,  but  he  was 
very  teachable,  and  seemed  quite  to  understand  the 
remarks  I  made  about  the  condition  of  his  mouth. 
The  habit  of  sucking  his  tongue  had  been  observed, 
but  no  one  ever  thought  that  any  ill  effects  would 
result  from  it ;  and  no  one  had  noticed  that  he 
could  not  make  his  front  teeth  meet  until  I 
pointed  it  out  to  the  parents.  The  lower  teeth  on 
the  right  side  were  completely  hidden  by  a  mass  of 
tartar,  but  there  was  no  dribbling  of  saliva,  and  the 
lips  met  without  much  effort. 


THE    TEMPOEARY    TEETH.  28 

An  attempt  was  made  to  correct  the  deformity 
by  the  use  of  a  strong  elastic  strap  on  each  side  of 
the  face,  attached  to  a  well-fitting  chin-piece  and  to 
a  sort  of  skull-cap,  consisting  of  a  fillet,  with  bands 
over  the  top  of  the  head,  from  front  to  back  and 
from  side  to  side,  an  arrangement  much  better  than 
a  close  cap.  The  apparatus  was  working  well,  and 
the  upper  and  lower  front  teeth  were  nearly  meeting, 
when  a  severe  illness  put  a  stop  to  the  treatment, 
and,  as  the  boy  had  to  be  sent  to  a  milder  climate 
when  he  was  well  enough  to  be  moved,  the  treat- 
ment was  necessarily  abandoned. 


Figure  8. — Showing  the  effect  of  sucking  the  tongue. 

Nurses  will  sometimes  teach  children  to  suck 
the  thumb  to  keep  them  quiet.  Of  course  it  is  done 
in  ignorance  of  the  possible  effect,  which  they  are 
generally  very  unwilling  to  believe  in,  even  after  the 
malformation  has  become  apparent  to  every  one, 
preferring  to  assign  any  other  reason  than  the  real 
one  for  the  disfigurement  of  the  child's  mouth,  and, 
perhaps,  never  suspecting  the  true  cause,  as  the 
change  in  the  form  of  the  jaw  is  gradual,  and  it  may 


24  DENTAL    PRACTICE. 

be  three  or  four  years  before  it  becomes  so  serious 
as  I  have  described.  It  is  another  point  on  which 
the  public  need  more  information,  although,  doubt- 
less, many  a  lip  will  curl  in  derision  at  the  sugges- 
tion that  any  more  knowledge  is  requisite  on  the 
subject  of  the  management  of  babies.  Sucking  the 
thumb  or  the  fingers  may  be  easily  cured  by  put- 
ting the  hand  into  a  thumbless  mitten,  which 
should  be  sewed  into  the  sleeve  of  the  frock  and  the 
night-gown,  so  that  the  thumb  and  fingers  will  be 
inseparable  and  sucking  impossible.  Half  measures 
will  be  of  no  use ;  it  must  be  made  literally  impos- 
sible until  the  habit  is  forgotten.  Sucking  the  lip 
or  tongue  is  much  more  difficult  to  cure,  and  pos- 
sibly the  treatment  may  have  to  be  deferred  until 
the  child  is  old  enough  to  wear  a  plate  that  is  made 
to  cover  the  whole  of  the  lower  teeth,  and  keep  the 
mouth  so  much  open  as  to  make  sucking  an 
impossibility. 

Beyond  the  curing  of  the  habit,  I  do  not  think  it 
is  well  to  attempt  any  treatment  of  these  cases  until 
the  child  is  older,  and  has  parted  with  all  or 
nearly  all  of  the  temporary  teeth. 


25 


CHAPTER  II. 


The    Permanent    Teeth. 

When  the  child  is  about  six  years  of  age,  if  a  boy, 
or  five  and  a  half,  if  a  girl,  we  may  begin  to  look  for 
the  first  permanent  molars ;  and  these  must  be 
watched  most  carefully,  for  there  are  no  other  teeth 
in  the  mouth  so  liable  to  be  defective.  Probably 
the  period  of  their  formation,  beginning  in  the  first 
month  of  infancy,  and  extending  through  all  the 
trials  and  illnesses  of  first  dentition,  has  much  to 
do  with  the  defective  structure  of  these  teeth  ;  but 
whether  this  is  so  or  not,  the  fact  remains  that  not 
ten  per  cent,  of  them,  in  the  mouths  of  the  middle 
and  upper  classes,  are  perfectly  formed  teeth.  The 
chief  defects  are  in  the  sulci,  between  the  cusps. 
All  the  other  teeth  that  have  a  grinding  surface  of 
cusps  and  sulci  are  later  in  development,  and  they 
certainly  average  better  than  the  first  molars,  which 
is  a  fairly  good  reason  for  thinking  that  their 
defective  nature  is  partly  owing  to  the  period  of 
formation.  There  is  often  a  want  of  perfect  union 
in  the  formation  of  enamel  in  the  sulci,  and  as 
every  fissure  that  will  admit  the  secretions  to  con- 
tact with  the  dentine  will  prove  to  be  a  weak  spot 
and  probable  starting-point  for  caries,  it  is  evident 
that  these  weak  spots  should  be  sought  for  as  soon 


26  DENTAL    PRACTICE. 

as  the  grinding  surface  of  the  tooth  has  emerged 
from  the  gum,  and  a  very  little  care  in  filling  the 
fissures  at  this  early  period  may  save  a  great  deal  of 
pain  and  trouble  later  on. 

Few  parents  are  aware  of  the  nature  of  these 
teeth,  and  it  is  therefore  the  duty  of  the  dentist  to 
instruct  them  when  to  look  for  these  pioneers  of  the 
permanent  denture,  and  of  the  importance  also  of 
looking  after  their  condition.  Popular  information 
on  these  subjects  is  greatly  needed,  and  should 
have  a  much  larger  space  in  the  public  papers  than 
is  conceded  to  it  at  present. 

Every  practitioner  is  aware  of  the  frequency  with 
which  children  suffering  from  pain  in  their  molars 
are  brought  to  us,  and  of  the  frightfully  broken 
down  and  hopeless  state  in  which  we  find  them  on 
such  occasions  ;  and  surely  it  is  not  charlatanism  to 
try  to  increase  the  knowledge  of  those  who  have  the 
care  of  children,  in  order  to  prevent  such  a  con- 
dition of  things.  If  one  wrote  so  that  it  was 
evidently  his  object  to  direct  attention  to  himself  as 
the  fountain  of  knowledge,  an  accusation  of  that 
nature  might  well  be  laid  at  his  door  ;  but  there  is 
no  doubt  that  a  sensitive  shrinking  from  this  charge 
is  the  chief  cause  of  the  want  of  popular  literature 
on  this  subject,  and  of  the  absurd  nonsense  that  we 
sometimes  see  in  the  public  prints  from  lay  sources. 

If,  however,  the  parents  err  from  ignorance,  they 
are  not  so  much  to  blame ;  but  if  the  dentist,  who 
has  knowledge  at  his  command,  if  not  in  his  posses^ 
sion,  commits  the.  I  am  sorry  to  say,  common  error 


THE    PERMANENT    TEETH.  27 

of  extracting  these  teeth,  merely  to  reheve  pain, 
without  a  thought  of  the  future  of  the  mouth,  what 
can  be  said  of  him  ?  If  it  was  important  to  retain 
the  temporary  molars  in  order  to  insure  the  pro- 
per lengthening  of  the  jaw  to  make  room  for  the 
permanent  molars,  there  is  still  greater  necessity 
for  the  preservation  of  the  latter,  inasmuch  as  they 
in  their  turn  are  necessary  for  the  proper  growth  of 
the  jaw  to  make  room  for  the  second  permanent,  or 
twelve-year  molars.  They  also  serve  an  important 
function  in  lengthening  the  rami,  for  as  they  are 
in  every  respect  larger  and  longer  teeth  than  the 
temporary  molars,  they  must  have  more  room  for 
this  additional  length.  Therefore  the  ramus  must 
lengthen  out  to  give  the  required  space,  and  it  is 
certain  that  this  growth  only  keeps  pace  with  the 
growth  of  the  roots  of  the  six-year  molar,  which  is 
rarely  complete  before  the  ninth  or  tenth  year.  It 
is  therefore  very  desirable  not  only  to  keep  these 
teeth,  but  also  to  keep  them  healthy,  to  keep  their 
pulps  alive ;  and  as  such  young  teeth  go  very  rapidly 
when  they  begin  to  decay,  they  should  be  examined 
often,  every  three  or  four  months,  and  every  cavity 
filled,  if  possible,  before  it  becomes  a  source  of 
danger  to  the  vitality  of  the  tooth. 

The  material  best  suited  for  filling  these  and 
any  other  permanent  teeth  that  may  decay  previous 
to,  or  during  the  constitutional  changes  at  puberty, 
is,  without  doubt,  a  preparation  of  gutta-percha.  I 
am  quite  sure  that  whatever  may  be  said  of  gold  as 
a  material  for  filling  teeth  after  the  sixteenth  year — 


28  DENTAL    PRACTICE. 

and  I  will  say  here  that  I  believe  there  is  no  other 
material  to  be  compared  to  it  for  the  teeth  that  are 
old  enough  and  dense  enough  to  stand  it — it  is  not 
fit  to  be  used  in  a  tenth  part  of  the  teeth  that 
one  has  to  treat  for  patients  who  have  not  attained 
that  number  of  years.  Gutta-percha  will  preserve 
the  teeth  at  this  early  age,  and  gold  may  do  so,  but 
I  believe  that  more  harm  than  good  is  generally 
done  by  using  the  latter  too  early.  It  is  better  in 
the  grinding  surface  of  molar  teeth,  such  as  we  are 
now  treating  of,  than  in  any  other  cavities  at  this 
time  of  life ;  but  I  say  it  does  harm,  because  it  sub- 
jects the  patient  to  a  needless  amount  of  suffering 
in  preparing  the  cavities  and  inserting  the  filling, 
and  thus  keeps  alive  the  dread  of  the  dentist's 
chair,  and  prevents  the  frequent  examinations  that 
are  so  necessary  ;  and  again,  because  in  using  a 
material  of  this  nature  we  convey  an  impression 
that  we  expect  it  to  be  a  perfect  safeguard  against 
further  decay.  Every  man  of  experience  in  our 
profession  may  judge  for  himself  whether  this 
impression  will  be  justified  by  the  result.  I  do  not, 
by  any  means,  intend  to  imply  that  all  gold  filling 
will  fail.  I  have  some  in  my  own  mouth  that  have 
protected  the  teeth  for  thirty-five  years  ;  but  I  was 
past  the  age  of  sixteen  when  the  first  filling  was 
made.  NVhat  I  do  mean  to  say  is,  that  a  large  per- 
centage of  gold  fillings,  made  in  the  teeth  of  patients 
under  sixteen  years  of  age,  do  and  will  constantly 
fail,  and  will  have  to  be  renewed,  and  that  it  would 
be  better  to  tell  the  parents  plainly  that  the  work  is 


THE     PERMANENT    TEETH.  29 

only  meant  to  save  the  teeth  from  further  decay 
until  the  child  is  old  enough  to  have  them  properly 
filled.  If  the  cavities  are  large,  the  gutta-percha 
should  be  protected  on  a  grinding  surface,  as  it  is 
liable  to  be  rapidly  worn  away.  This  may  be  done 
by  using  the  porcelain  caps  prepared  for  this  pur- 
pose, or  by  making  a  cap  of  thin  gold-plate,  swaged 
to  correspond  to  the  surface  it  is  to  replace,  and  a 
loop  or  stud  soldered  to  the  under  side  to  retain  it 
in  position.  A  quantity  of  these  may  be  prepared 
of  different  sizes  and  shapes,  but  if  one  is  not 
readily  found  to  fit  the  cavity,  it  may  easily  be  cut 
and  trimmed  to  the  required  form.  Some  gutta- 
percha should  be  pressed  into  the  loop,  or  around 
the  stud,  and  then  when  the  tooth  is  filled,  and 
before  the  filling  gets  hard,  the  cap  may  be  well 
warmed  over  the  lamp  and  carefully  pressed  into 
its  place.  A  filling  of  this  character  is  a  perfect 
protection  to  the  tooth,  and  the  tooth  is  very  com- 
fortable at  once,  which  is  not  always  the  case  when 
the  filling  is  wholly  metallic,  for  metal  is  a  quick 
conductor,  and  in  contact  with  the  sensitive  surface 
of  a  tooth  it  may  for  weeks  make  the  patient  pain- 
fully conscious  of  thermal  changes. 

I  have  been  using  these  gold  caps  for  years, 
and  have  even  described  them  in  a  paper  read  before 
the  Odontological  Society  of  New  York,  in  1881,  as 
an  idea  of  my  own,  and  it  was  a  surprise  to  me,  on 
looking  over  an  old  report  of  a  meeting  of  the 
Pennsylvania  Association  of  Dental  Surgeons,  in 
March,  1877,  to  find  a  full  description,  with  illus- 


30  DENTAL    PRACTICE. 

trations,  of  the  same  thing,  by  Dr.  Charles  Essig,  of 
Philadelphia.  I  can  only  say  that  I  did  not  intend 
to  claim  another  man's  ideas  as  my  own,  and  as 
Dr.  Essig  carries  out  the  idea  more  perfectly  than 
I  have  done,  I  will  take  the  liberty  of  copying  the 
illustrations,  with  his  remarks,  as  reported  in  the 
Dental  Cosmos,  vol.  19,  p.  314. 

"Professor  Chas.  Essig  presented  some  models 
of  very  badly  decayed  teeth,  which,  he  said,  he  had 
treated  according  to  the  plan,  or  idea,  proposed  by 
Dr.  Bing,  of  Paris,  France.  Instead,  however,  of 
using  a  simple  plate,  or  disk,  with  loops  soldered  to 
the  under  surface  of  the  plate,  as  proposed  by  Dr. 
Bing,  he  proceeded  as  follows  : — The  contour  of  the 
tooth  was  restored  in  wax,  after  which  an  impres- 
sion in  plaster  was  taken,  from  which  a  model  was 
made,  and  from  this  a  die  and  matrix.  With  these 
plates  were  swaged,  covering  the  defective  parts  of 
the  teeth  to  be  treated  or  filled,  and  on  the  inner 
surface  of  these  plates  loops  of  gold,  or  platina  wire, 
were  soldered.  Gutta-percha,  or  Hill's  stopping,  was 
•  now  softened  and  carefully  packed  on  these  plates 
and  through  the  loops,  and  the  tooth  was  likewise 
filled  with  gutta-percha.  The  plates  were  now  put 
in  the  mouth  over  the  teeth  they  were  intended  to 
cover,  and  by  means  of  a  heated  instrument  the 
gutta-percha  in  the  tooth  and  on  the  plate  was 
softened  and  united,  and  the  edges  of  the  plate 
burnished  down  to  the  remains  of  the  tooth.  When 
finished  the  operation  presented  the  appearance  of  a 
well-executed  and  laborious  gold  filling.     Dr.  Essig 


THE    PERMANENT    TEETH.  31 

stated  that  the  material,  Hill's  stopping,  was  well 
known  as  most  excellent  for  the  preservation  of  the 
teeth,  cases  having  been  brought  to  his  attention 
where  it  had  effectually  done  this  for  fifteen  years, 
in  localities  not  subjected  to  the  attrition  of  masti- 
cation. The  object  of  these  gold  caps  was  to  over- 
come this  liability  to  wear  in  the  material.  The 
plates  were  of  pure  gold  (made  from  scraps  of  gold 
foil),  which  was  milled  down  to  number  29  of  the 
standard  gauge.  Dr.  Essig  laid  no  claim  to 
originality  in  this  matter,  according  the  idea 
entirely  to  Dr.  Bing.  The  only  point  of  difference 
in  what  he  now  proposed  was  the  attempt  at 
restoration  of  contour,  which  Dr.  Bing  did  not 
resort  to,  so  far  as  he  was  informed.  For  the  better 
understanding  of  the  two  methods,  Dr.  Essig  illus- 
trated both  plans  on  the  blackboard.  Dr.  Bing's 
plan  was  to  dress  down  the  crown  of  the  tooth  ;  the 
entire  cavity  of  decay  was  now  filled  with  Hill's 
stopping,  and  a  pure  gold  plate,  to  which  two  loops 
of  gold  or  platina  were  soldered  (thus  r\  r\  ), 
was  warmed,  and  while  warm  was  pressed  into  the 
gutta-percha  already  inserted  into  the  tooth,  after 
the  cooling  of  which  the  edges  of  the  gold  could 
be  neatly  burnished  down  to  the  edges  of  the 
tooth.  By  this  plan  onhj  simple  crown  cavities  were 
attempted.  Dr.  Bing  kept  on  hand,  ready  made 
for  these  cases,  thin  plates  of  different  sizes,  and 
applied  them  in  size  to  suit  each  case.  Dr.  Essig 
had  acted  on  the  suggestion,  but  proposed  to 
extend  the  field  of  its  usefulness  in  cases  where 


32 


DENTAL    PRACTICE. 


proximate,  buccal,  or  palatal  walls  were  consumed 
by  decay.  He  proposed  to  restore  the  tooth  in 
shape  as  well  as  usefulness  as  follows  : — cutting 
down  the  tooth  wherever  a  comparatively  firm 
border  could  be  obtained,  he  restored  the  contour 
in  wax,  and,  by  having  the  patient  close  the  jaws, 
obtained  from  the  antagonizing  tooth  a  complete 
and  proper  occlusion.  By  this  plan  teeth  in  almost 
any  stage  of  decay  might  be  made  serviceable  for  a 
considerable  time.  The  idea  will  be  better  under- 
stood by  the  following  diagrams.     (Figs.  9  and  10.) 


,t0I\ul^. 


Figure  9. 


Fi.'uie  10. 


The  case  illustrated  a  was  now  restored  in  wax  as  in 
h ;  when,  as  stated,  an  impression  in  plaster  would 
be  taken,  plaster  model  made,  and  die  and  counter- 
die  obtained  ;  a  gold  cap  could  now  be  swaged,  and 
loops  soldered  to  it,  as  represented  in  Fig.  10.  The 
body  of  this  gold  cap  is  filled  with  softened  Hill's 
stopping,  as  well  as  the  remains  of  the  tooth.  The 
cap  is  placed  in  position,  and  with  a  heated  instru- 
ment the  temperature  is  conveyed  through  the  gold 


THE    PEEMANENT    TEETH.  33 

cap  to  the  gutta-percha  in  both  tooth  and  cap.  The 
jaws  may  now  be  closed  while  the  gutta-percha  is 
soft,  and  when  cooled  off,  the  excess  of  Hill's  stop- 
ping removed,  and  the  edges  of  the  gold  burnished 
down  to  the  tooth.  To  a  cursory  glance  the  whole 
operation  presents  the  appearance  of  an  artistically 
executed  contour  gold  filling.  These  dies  and  plates 
may  all  be  made  by  assistants  in  the  laboratory, 
,  and  the  entire  operation  may  not  call  for  more 
than  fifteen  to  thirty  minutes  of  the  operator's  time. 
Dr.  Essig  gave  the  preference  to  Hill's  stopping 
over  oxy-chloride  of  zinc  in  these  frail  teeth,  as  he 
said  he  had  found  that,  when  large  masses  of  this 
were  used,  it  had  sufficient  expansive  force  to  some- 
times break  a  weak  wall  of  enamel." 

When  a  child  is  brought  to  us  with  toothache  in 
one  of  these  teeth,  as  will,  unfortunately,  often  be 
the  case — for  all  parents  will  not  remember  our 
teaching,  or  take  the  care  which  we  have  told  them 
would  be  necessary  to  prevent  pain — we  must  first 
ascertain  whether  it  is  primary  or  secondary  tooth- 
ache, as  in  the  case  of  the  temporary  teeth,  page  10, 
and  then  proceed  to  devitalize  the  pulp,  or  to  open 
the  pulp  cavity  and  give  vent  to  the  gases  or  pus,  as 
the  case  may  require.  But  as  this  is  a  permanent 
tooth,  we  must  try  to  preserve  it,  at  least  until  the 
jaw  is  sufficiently  grown  to  make  room  for  the 
eruption  of  the  twelve-year  molar. 

If  devitalization  is  necessary — and  we  must  be 
quite  sure  that  it  is  necessary,  from  satisfaction  of 
our  own  judgment,  more  than  from  the  patient's 

c 


34  DENTAL    PRACTICE. 

convictions  or  statements — it  will  be  best  to  remove 
the  arsenical  dressing  within  a  week,  and  then, 
after  cleansing  the  cavity,  and  making  a  sufficient 
opening  into  the  pulp  cavity  to  permit  the  free 
escape  of  gases,  a  simple  dressing  of  cotton  and 
stiff  sandarac  varnish  may  be  placed  in  the  tooth, 
to  remain  about  a  month,  or  until  the  pulp  has 
separated,  by  sloughing,  from  its  connections  at  the 
apical  foramen.  Then,  after  carefully  removing  all 
the  decomposing  matter  with  fine  barbed  instru- 
ments, and  syringing  with  a  five  per  cent,  solution 
of  carbolic  acid— or  any  other  antiseptic  that  can  be 
used  in  sufficiently  weak  dilution  to  retain  its  anti- 
septic qualities,  without  so  much  of  the  escharotic 
nature  as  to  be  unpleasant  in  the  mouth — the  roots 
may  be  filled.  There  are  many  ways  of  doing  this, — 
some  dentists  insisting  that  gold  is  the  only  safe 
material  for  filling  roots  ;  some  would  have  this 
used  in  the  form  of  wire  and  screwed  in,  while 
others  can  only  be  satisfied  with  soft  foil,  malleted 
in  ;  some  prefer  tin,  some  gutta-percha,  others  oxy- 
chloride,  and  others  again  prefer  amalgam.  Most 
operators  enlarge  the  pulp  canal  very  much  in 
order  to  facilitate  the  process  of  filling,  and,  per- 
haps naturally  enough,  every  operator  thinks  his 
own  method  the  best,  if  not  the  only  method  of 
performing  the  operation  ;  but  all  that  is  really 
wanted  is  to  occupy  the  space,  so  as  to  exclude 
everything  that  is  liable  to  decomposition.  A  root- 
filling  is  not  exposed  to  the  action  of  the  oral 
fluids,  nor  to  attrition ;  therefore  it  cannot  be  neces- 


THE    PERMANENT    TEETH.  35 

sary  to  exi^end  so  much  labour  as  will  be  required 
to  pack  gold,  or  tin,  into  a  long  narrow  root  canal. 
Oxy- chloride  of  zinc  does  very  well  indeed,  but  to 
ensure  success  with  it,  a  few  fibres  of  cotton  must 
be  used  to  carry  the  cement  to  the  apex  of  the  root. 
The  same  may  be  said  of  a  solution  of  gutta-percha ; 
but  it  is  a  question  whether  cotton  alone,  properly 
packed  into  a  dry  root,  will  not  be  as  effective  as 
anything  else  for  this  purpose,  and,  if  the  fibre 
carries  with  it  a  little  sandarac  varnish,  I  am  quite 
sure  it  wiU  make  as  perfect  and  durable  a  filling  as 
can  be  necessary.  The  root  may  be  dried  with  a 
thin  twist  of  bibulous  paper ;  then,  as  one  can  never 
be  quite  sure  that  no  particle  of  the  nerve  is  left,  or 
that  there  is  no  leakage  of  lymph,  or  blood,  into  the 
end  of  the  root  before  it  is  possible  to  pack  a  filling 
to  occupy  the  space,  it  is  best  to  moisten  a  few 
fibres  of  cotton  with  carbolic  acid,  and  pack  these 
carefully  to  the  apex  of  the  root,  taking  up  any 
suri)lus  acid  with  another  twist  of  paper ;  then  a 
few  more  fibres  of  clean  cotton,  and  more  and  more 
until  tlie  root  is  filled.  I  think  in  the  eases  of 
very  young  patients  it  is  best  to  use  cotton  alone, 
because  it  is  desirable  to  be  as  expeditious  as  pos- 
sible, and  because,  a  little  later,  it  is  likely  enough 
that  it  may  be  advisable  to  extract  the  four  first 
molars  to  give  more  space  to  the  rest  of  the  teeth. 
If  this  is  not  found  desirable,  we  shall  want  to  use 
a  filling  in  the  crown  cavity  of  a  more  permanent 
nature  than  we  should  insert  now,  and  it  may  be 
just   as   well   that   the    root-filling   should   be   re- 


36  DENTAL    PRACTICE. 

movable.  After  treating  all  the  roots  in  this  way, 
the  crown  cavity  may  be  filled  with  gutta-percha, 
with  or  without  a  gold  or  porcelain  cap,  as  may 
seem  desirable ;  or  with  amalgam ;  but  if  the  latter 
material  is  used,  it  is  best  to  half  fill  the  cavity  with 
gutta-percha  and  cover  it  with  amalgam.  In  the 
majority  of  cases  the  tooth  will  be  comfortable  and 
useful ;  but  it  must  be  borne  in  mind  that  no  one 
can  be  sure  of  permanent  comfort  in  a  dead  tooth, 
because,  with  every  precaution,  a  failure  is  always 
possible,  and  especially  is  this  the  case  with  these 
teeth  while  the  jaw  is  still  growing  to  make  room 
for  the  twelve-year  molars.  It  may  be  that  the 
more  active  vascularity  necessary  for  growth  is  less 
tolerant  of  the  half-dead  substance  of  dentine  than 
is  the  case  later,  when  growth  has  ceased ;  but  it  is 
certain  that,  from  some  cause,  failures  are  more 
frequent  in  the  treatment  of  these,  than  of  dead 
teeth  in  the  adult  mouth. 

The  term  dead  tooth  is  in  common  use,  but  it 
conveys  a  wrong  impression ;  for  if  a  tooth  were 
absolutely  dead,  it  could  not  be  tolerated  in  the 
mouth ;  but  when  the  pulp  has  been  extirpated, 
the  tooth  receives  the  necessary  sustenance  through 
the  peri-dental  membrane,  and  is  thus  kept  in  a 
tolerably  comfortable  condition.  This  membrane, 
however,  sometimes  resents  the  increased  labour 
that  is  thus  thrown  upon  its  vessels,  and  a  slight 
soreness  is  common  enough  in  such  teeth,  when, 
from  any  cause,  the  strength  of  the  patient  is  below 
par,   as    from    a    cold,   or   over -work,   mental   or 


THE    PERMANENT    TEETH.  37 

physical.  Soreness  of  this  nature  almost  invariably 
follows  the  extirpation  of  the  nerve  within  a  few 
weeks,  but  is  usually  quite  controllable  by  the  appli- 
cation of  a  counter-irritant  to  the  external  surface 
of  the  gum.  Tincture  of  pellitory  (Pyrethrwn  ana- 
cyclus)  is  peculiarly  valuable  in  these  cases,  used  on 
the  finger  for  rubbing  the  gum,  or,  in  more  urgent 
cases,  on  a  piece  of  lint  laid  upon  the  gum. 

If  the  toothache  is  caused  by  the  presence  of  a 
putrescent  pulp  in  the  tooth,  it  is  best  to  simply 
open  the  pulp  cavity,  syringe  with  warm  water,  and 
tell  the  patient  to  come  .again  in  three  or  four  days, 
by  which  time  we  can  probably  open  the  tooth  into 
the  roots,  remove  all  the  putrid  matter,  and  give  the 
roots  an  antiseptic  dressing.  This  treatment  will 
have  to  be  renewed  several  times,  with  thorough 
syringing,  until  the  roots  are  quite  clean  and  free 
from  any  fetid  smell,  when  they  may  be  filled.  But 
if  the  pulp  dies  before  the  child  is  nine  years  old, 
there  may  be  a  difficulty  in  treating  the  roots,  be- 
cause the  foramina  are  larger  than  the  canals,  as 
described  in  the  chapter  on  temporary  teeth  ;  but 
in  this  case  it  will  be  owing  to  incomplete  forma- 
tion.      (Fig    11.)      The   age    is    not,    however,    a 


Figure  11. — Showing  roots  of  bicuspid  and  molar  teeth  not  fully  developed, 
the  foramina  being  very  large. 

reliable  criterion.      We  must  test  with  a  probe,  and 


38  DENTAL    PEACTICE, 

if  we  find  the  canal  widening  towards  the  apex,  we 
may  as  well  treat  it  as  described  in  the  case  of  the 
temporary  tooth  (page  15),  and  try  to  keep  the 
roots,  at  least  until  the  twelve-year  molars  appear, 
for  there  will  be  no  further  development  of  roots 
after  the  death  of  the  pulp,  and  if  incomplete  then, 
they  will  remain  so. 

As  soon  as  the  first  permanent  molars  are  fairly 
through  the  gum,  we  may  begin  to  look  for  the 
lower  central  incisors.  We  often  see  them  sooner, 
sometimes  before  any  of  the  molars  appear,  but  it 
is  not  in  regular  order.  These  teeth  are  a  great 
source  of  anxiety  to  parents,  because  they  are  so 
often,  apparently,  out  of  place.  I  say  apparently, 
because  it  really  seems  so  to  one  who  is  not  ac- 
customed to  watch  the  progress  of  second  dentition ; 
but  it  is  only  in  appearance,  for  the  teeth  may  be 
far  inside  the  dental  arch  without  any  real  cause 
for  anxiety  about  them,  and  without  any  need  of 
professional  aid,  other  than  the  extracting  of  the 
two  temporary  centrals,  if  they  have  not  already 
come  out  with  a  little  home  assistance. 

It  is  a  matter  of  almost  daily  occurrence  for 
children  to  be  brought  to  us  with  these  teeth  making 
their  appearance  more  or  less  inside  the  arch,  or 
slightly  turned  in  a  diagonal  position,  and  probably 
the  cutting  edges  serrated.  The  parents  are  anxious 
that  we  should  do  something  at  once  to  remedy 
these  deformities,  as  they  consider  them ;  usually, 
however,  the  dentist's  assurance  that  the  teeth  will 
move  forward  to  their  proper  place  as  soon  as  the 


THE    PERMANENT    TEETH.  39 

jaw  has  grown  sufficiently  to  make  room  for  two 
teeth  that  are  half  as  large  again  as  the  two  which 
have  occupied  that  position,  and  that  the  serrations 
are  perfectly  normal,  and  will  wear  away  as  soon 
as  the  teeth  come  into  use,  will  satisfy  them.  But 
whether  they  are  satisfied  or  not,  nothing  will 
justify  the  dentist  in  yielding  to  the  desire  to  have 
something  done  at  once,  and  extract  four  teeth  to 
make,  room  for  two,  or  a  central  and  a  lateral  to 
make  room  for  a  central.  We  should  never  extract 
more  than  the  precise  number  we  wish  to  make 
room  for,  and  leave  the  rest  until  the  appear- 
ance of  more  new  teeth  shows  the  necessity  for 
further  extraction.  If  the  new  central  is  very  far 
inside  the  arch,  we  may  find  that  there  has  been 
very  little  absorption  of  the  root  of  the  temporary 
central,  but  it  must  be  removed  nevertheless,  and  it 
will  be  enough  to  do  this.  Nothing  more  will  be 
needed,  although  the  tooth  may  seem  much  wider 
than  the  space  it  has  to  occupy.  I  have  seen 
several  cases  where  the  permanent  central  appeared 
almost  directly  behind  the  temporary  lateral ;  but 
it  may  be  taken  for  granted  that  it  is  a  central  out 
of  place,  and  extraction  of  the  temporary  central 
will  almost  certainly  make  it  right.  There  is  always 
an  appearance  of  justification  for  the  operator,  who 
thinks  it  right  to  get  these  teeth  quickly  into  place 
by  extracting  more  than  the  proper  number,  for  a 
satisfactory  result  is  quickly  visible  to  the  parent. 
I  have  often  seen  the  four  central  incisors  occu- 
pying the   position  of  the  temporary  incisors   and 


40  DENTAL    PEACTICE. 

canines,  and  certainly  they  looked  very  nice ;  and 
I  have  no  doubt  that  the  dentist  who  extracted  the 
six  teeth  to  make  room  for  four,  thought  himself, 
and  was  thought  by  the  parents,  to  be  a  clever 
fellow  to  have  straightened  a  set  of  irregular  teeth 
so  quickly.  But  the  error  will  be  obvious  two  or 
three  years  later,  when  the  permanent  canines 
appear.  The  first  and  second  bicuspids  may  be 
expected  before  the  canine,  and  the  distal  surface 
of  the  lateral  incisor  and  the  mesial  surface  of  the 
first  bicuspid  will  be  in  close  contact  before  the 
canine  appears.  The  latter  tooth  is  generally  de- 
veloped somewhat  outside  the  arch,  but  in  this  case 
it  might  be  a  supernumerary  tooth,  for  there  is 
absolutely  no  room  for  it,  and  the  cause  of  this  is 
plainly  and  unmistakably  the  extraction  of  six  teeth 
to  make  room  for  four.  The  incisors,  if  left  to  work 
their  own  way,  would  have  been  pushed  forward  by 
the  pressure  of  the  tongue,  until  they  made  room 
for  themselves,  with  the  temporary  canines  still  in 
position  ;  but  the  extractions  simply  stopped  the 
growth  of  the  jaw,  because  there  was  no  longer  any 
occasion  for  expansion,  as  the  necessary  space  had 
been  provided  by  professional  interference. 

The  upper  centrals  are  the  next  in  order,  and 
they,  too,  are  a  source  of  anxiety  to  the  fond 
mother,  who  naturally  wishes  her  child  to  have 
pretty  and  regular  teeth.  They  are  so  large,  or 
they  overlap,  or  they  are  not  quite  straight — would 
it  not  be  best  to  take  out  the  little  tooth  that  seems 
to  make  the  new  one    stand  out  so  at  that  side  ? 


THE    PERMANENT    TEETH.  41 

How  often  we  hear  such  suggestions,  and  how  trite, 
to  us,  seems  the  reply  that  there  is  no  cause  for 
anxiety ;  that  the  tooth  which  seems  so  large  now, 
will  not  appear  so  out  of  proportion  when  the  face 
has  grown  more  mature ;  that  having  so  much  more 
breadth  than  the  baby  teeth,  they  cannot  stand 
quite  in  the  same  position  the  others  occupied. 
This  desire  to  have  something  done  at  once  to 
hasten  nature's  work  is  a  temptation  that  is  often 
unconsciously  held  out  to  the  young  practitioner; 
and  how  many  have  yielded  to  it,  not  always  for  the 
mere  fee,  but  to  secure  a  patient,  or  from  a  want  of 
confidence  in  their  own  judgment,  a  wish  to  oblige, 
or  perhaps  from  ignorance  of  the  right  treatment. 
It  has  been  a  fault  of  teachers  in  our  profession, 
that  they  have  told  us  too  little  about  how  and 
when  nature  should  be  assisted,  and  when  left  to 
herself,  in  the  management  of  the  mouth,  while 
second  dentition  is  going  on.  The  pupil  is  taught 
to  read,  and  then  he  is  at  once  passed  on  to  classics 
and  mathematics.  The  text-books  tell  him  all 
about  the  origin  and  development  of  the  teeth,  and 
the  minute  anatomy  and  relation  of  all  the  sur- 
rounding tissues,  and  then  go  on  to  tell  him  how 
the  teeth  should  be  treated  at  maturity.  So  the 
young  man  begins  a  practice  with  the  idea  that  he 
is  a  dentist,  when  he  knows  how  many  teeth  should 
be  in  the  mouth  at  a  given  age,  and  how  to  make  a 
gold  filling.  The  hiatus  that  is  left  in  his  training 
must  be  filled  up  by  the  teachings  of  his  own 
experience,  and  naturally  he  makes  some  mistakes. 


42  DENTAL   PRACTICE. 

The  same  rule  that  applies  to  the  lower  teeth 
should  be  the  guide  in  relation  to  extracting  for  the 
upper  incisors,  viz.,  not  to  extract  more  than  the 
precise  number  we  wish  to  make  room  for.  We 
must  let  nature  do  her  own  work  as  far  as  possi- 
ble, giving  her  only  such  aid  as  is  imperatively 
demanded.  But  if  we  find  an  upper  incisor 
closing  inside  the  lower  arch^ — (Fig.  12) — we  may 


Figure  12. — Showing  a  central  incisor  which,  when  the  mouth  is  closed, 

would  be  found  to  shut  inside  the  lower  arch,  and  a  plate  and  spring 

for  moving  the  tooth  into  its  proper  position. 

be  quite  sure  that  here  is  a  case  that  can  never 
correct  itself,  and  we  must  temporarily  prevent 
the  contact  by  covering  the  back  teeth  with  a  plate 
thick  enough  to  prevent  the  front  ones  meeting,  and 
at  the  same  time  apply  pressure  to  the  lingual 
surface  of  the  tooth  to  move  it  forward.  This  may 
be  done  with  a  vulcanite  plate,  having  a  spring  of 
gold  wire — flattened  with  the  hammer  and  not 
annealed — embedded  in  the  substance  of  the  vul- 
canite. 


THE  PEKMANENT  TEETH.  43 

With  this  simple  apparatus  the  work  can 
be  done  very  quickly ;  in  some  cases  that  I  have 
treated,  the  tooth  has  moved  an  eighth  of  an 
inch  in  a  week ;  but  it  is  never  advisable  to  under- 
take these  cases,  unless  we  are  sure  of  the  hearty 
co-operation  of  parents  and  child,  else  we  may  be 
in  many  ways  thwarted  in  our  endeavours.  There 
is  not  much  pain,  but  the  tooth  becomes  a  little 
sore,  and  the  plate  is  removed  at  once,  or  the  child 
cannot  eat  with  such  a  clumsy  thing  in  the  mouth, 
and  it  is  laid  aside  at  meal  times ;  the  consequence 
is  that  no  progress  is  made,  because  five  minutes 
without  the  plate  may  undo  the  work  of  twenty- 
four  hours.  It  is  the  wisest  course  simply  to  point 
out  the  fault,  and  show  how  it  can  be  remedied,  and 
then,  if  the  parents  are  eager  to  have  it  done,  it  is 
easy  enough  to  do  it ;  but  if  the  dentist  is  the  only 
person  who  feels  any  interest  in  these  matters,  very 
little  good  will  result  from  his  efforts.  Good 
impressions  are  an  absolute  necessity,  for  the  plates 
must  fit  accurately,  and  great  care  must  be  taken 
with  the  plaster  casts,  to  prevent  the  cusps  of  the 
teeth,  over  which  the  plate  is  to  fit,  from  being 
broken  off.  I  have  found  some  of  the  preparations 
of  mixed  gums  for  taking  impressions  to  answer 
admirably  for  this  purpose. 

Sometimes  both  the  upper  centrals,  or,  if  they 
have  erupted,  the  laterals  also,  are  found  shutting 
inside  the  lower  arch,  forming  what  is  called  an 
"  underhung"  jaw,  although  overhung  would  be  a 
more  appropriate  description.     I'his  may  be  treated 


44 


DENTAL    PRACTICE. 


with  a  similar  plate,  with  a  spring  on  each  side, 
but  it  will  take  more  time,  as,  if  the  pressure  is 
too  strong,  the  springs  will  throw  the  plate  off. 
In  some  cases  it  may  be  necessary  to  tie  the 
plate,  or  fasten  it  with  screws  through  the  sub- 
stance of  the  plate,  into  shallow  indentations  in  the 
buccal  surfaces  of  the  temporary  molars — these 
indentations  having  been  made  with  a  drill  through 
the  screw-hole  in  the  plate.  In  these  cases  inquiry 
should  be  made  whether  the  child  has  not  been  in 
the  habit  of  sucking  the  fingers,  and  whether  this 
habit  is  not  still  kept  up  while  the  child  is  asleep. 

A  tooth  may  be  so  misplaced  in  the  arch,  that  it 
will  present  the  mesial  or  distal  surface  to  the  front, 
and  in  such  a  case  two  springs  will  be  necessary, 
one  from  the  palatine  portion  of  the  plate,  pressing 
on  the  inner  angle,  and  the  other  from  the  buccal 
portion  of  the  plate,  pressing  on  the  outer  angle,  so 
as  to  obtain  a  turning  force.     Fig.  13  shows  a  good 


Figure  13. — Showing  a  central  incisor  which  should  be  turned  in  its  socket, 

and  a  lateral  which  should  be  pressed  forward,  also  the  form  of  plate  and 

arrangement  of  springs  for  regulating  the  same. 


THE    PERMANENT    TEETH.  45 

example  of  such  an  irregularity,  the  right  central 
being  very  much  turned,  and  the  right  lateral 
shutting  inside  the  lower  arch.  They  were  easily 
straightened  with  such  a  plate  as  I  have  described. 
It  will  be  found  that  strong  pressure,  often  in- 
creased by  bending  the  springs,  and  the  impossi- 
bility of  contact  with  the  lower  teeth,  owing  to  the 
substance  of  vulcanite  over  the  grinding  surfaces  of 
the  molars,  will  soon  correct  such  faults  as  these. 
But,  unlike  the  other  cases  that  have  been  men- 
tioned, in  which,  if  the  teeth  are  once  outside  the 
lower  arch,  and  shutting  slightly  past  the  cutting 
edges  of  the  lower  teeth,  not  merely  edge  to  edge, 
they  cannot  easily  get  back  to  the  old  position,  a 
tooth  that  is  turned  in  the  socket  may,  and  probably 
will,  go  back  to  its  old  place  if  it  is  not  held  fast, 
until  the  new  alveolus  is  formed  around  it.  The  best 
way  I  have  found  to  do  this  is  to  make  a  vulcanite 


Fignre  14. — Showing  plate  with  clip  over  the  cutting  edge  of  the  central 
incisor,   to   keep  it  in  its  new   position  until   the   alveolus  closes  firmly 

around  it. 


46  DENTAL    PEACTICE. 

plate  having  a  strip  of  gold  fitted  to  the  lingual 
surface  of  the  tooth,  and  bent  over  the  cutting  edge, 
and  up  the  labial  surface  sufficiently  to  hold  the 
tooth  firmly  in  its  new  position.  (Fig.  14.)  This 
should  be  worn  three  months,  or  until  the  tooth 
feels  quite  firm  and  strong  in  its  new  socket. 

The  lower  and  then  the  upper  laterals  are  now  to 
be  looked  for.  The  latter  are  more  frequently  than 
any  other  teeth  in  the  mouth  liable  to  be  mis- 
placed, the  malposition  usually  being  that  they 
are  a  little  inside  the  arch,  and  if  it  is  found  on 
closing  the  jaws,  that  either  or  both  of  them  shut 
inside  the  lower  arch,  a  plate  like  those  previously 
described  will  soon  put  them  right. 

These  are,  I  believe,  all  the  cases  in  which  the 
use  of  regulating  apparatus  at  this  early  age  is 
really  necessary.  The  more  complicated  cases  are 
better  left  until  the  bicuspids  and  canines  are  well 
established,  as  we  can  then  judge  better  what  we 
must  do,  how  to  retain  the  apparatus  in  the  mouth, 
and,  if  time  is  required  for  the  treatment,  need  not 
fear  that  we  are  interfering  with  the  eruption  of 
new  teeth. 

There  is  so  much  variation  in  the  ages  at  which 
children  change  their  teeth,  that  no  fixed  period  can 
be  stated  for  the  appearance  of  any  of  the  permanent 
set ;  but  in  the  case  of  well-nourished  and  well- 
cared  for  children,  we  may  expect  to  see  all  the 
incisors,  upper  and  lower,  before  the  expiration  of 
the  ninth  year ;  and  in  a  large  number  of  cases, 
of  girls  especially,  who  are  generally  a  little  more 


THE    PERMANENT    TEETH.  47 

forward  than  boys  in  this  respect,  it  will  be  twelve 
months  earlier. 

The  first  or  anterior  bicuspids  are  the  next  in 
order ;  but  it  is  by  no  means  an  uncommon  thing 
to  see  the  second  or  posterior  bicuspid  before  the 
first  appears ;  indeed,  it  is  a  matter  of  extreme  un- 
certainty when  and  in  what  order  the  bicuspids 
will  make  their  appearance.  In  the  majority  of 
cases,  however,  we  shall  see  them  all  before  the  end 
of  the  eleventh  year,  and  the  canines  a  year  later. 
In  the  meantime  all  the  new  teeth  must  be 
carefully  examined  every  three  or  four  months  for 
indications  of  approximal  decay,  which  the  prac- 
tised eye  will  detect  by  the  appearance  of  slight 
opacity,  long  before  the  patient  is  aware  of  any 
defect  in  the  tooth.  The  upper  incisors  are  pecu- 
liarly liable  to  this,  and  their  position  in  the  mouth 
renders  it  a  matter  of  extreme  importance  to  detect 
and  check  the  first  symptoms  of  caries,  so  that  the 
appearance  of  the  mouth  may  not  suffer.  Young 
practitioners  should  accustom  themselves  to  the 
constant  use  of  the  mirror  in  these  examinations. 
A  good  mirror,  kept  warm  by  dipping  it  in  hot 
water,  to  prevent  condensations  from  the  breath 
upon  its  surface,  will  be  of  the  greatest  possible 
service  to  the  operator,  enabling  him  to  detect  the 
earliest  appearance  of  that  whitish  opacity  which 
indicates  the  progress  of  caries  from  the  interstices. 
Holding  the  mirror  so  as  to  throw  a  strong  light 
upon  the  lingual  surface  of  the  tooth  makes  this 
opacity   distinctly    visible,   in    many    cases   before 


48 


DENTAL   PRACTICE. 


sensibility  in  the  tooth  has  caused  a  suspicion  of  mis- 
chief.    Famiharity  with  the  use  of  the  mirror,  and 

with  the  use  of  instru- 
ments from  the  reflected 
image,  will  be  found  to 
be  a  great  advantage  in 
nearly  all  operations  on 
the  teeth.  The  silvering 
of  a  good  mirror  can  and 
should  be  done  in  such  a 
manner  that  it  cannot  be 
affected  by  moisture,  and 
the  handle  should  be  broad 
and  thin,  so  that  it  can 
be  held  under  perfect  con- 
trol between  the  fingers, 
leaving  the  finger  ends 
free  for  other  uses.  Figs 
15  and  16  will  show  the 
form  of  handle  which  I 
have  found  most  con- 
venient for  use,  and  the 
manner  of  holding  it 
while  operating  on  front 
teeth  is  shown  in  Fig.  17. 
It  is  a  great  assistance 
to  the  dentist  to  be  able 
to  work  with  the  mirror, 
as  he  can  then  do  anything 
^.   ,^  that  is   necessary  in  the 

Fig.  15.— Showing       Fig.  16.— Side  .  ... 

form  of  mirror.         view  of  same,    preparation   of    CaVltlCS   in 


THE    PERMANENT    TEETH. 


49 


approximal  surfaces,  and  packing  the  fillings,  with- 
out resorting  to  the  use  of  wedges  to  press  the  teeth 
apart,  and  without  cutting  away  the  labial  surface 
of  the  tooth,  and  so  spoihng  its  appearance.  All  the 
cutting  away   should  be  from  the  lingual   surface, 


Figure  17.— Manner  of  holding  the  mirror,  so  as  to  leave  the  fingers  free 
for  holding  the  lips  back,  holding  the  napkin,  etc.,  etc. 

and  if  an  0  0  dividing  file  can  be  passed  between  the 
teeth,  it  is  all  that  is  necessary  to  take  away  from 
the  labial  approximal  surface,  for  any  filling,  no 
matter  how  extensive  the  decay  may  be,  provided,  of 
course,  that  the  labial  surface  is  not  already  broken 
down  before  the  treatment  is  commenced.  But, 
fortunately  perhaps,  caries  in  front  teeth  will  have 
made  most  serious  progress  before  the  labial  surface 
breaks  down,  because  the  action  of  the  front  teeth 
in  biting  the  food  comes  upon  the  lingual  surface, 
and  as  that  breaks  down,  the  attention  of  even  the 


50  DENTAL    PEACTICE. 

most  careless  person  is  called  to  the  mischief  that 
is  going  on  by  the  sharpness  of  the  broken  edges 
of  the  cavity,  and  doubtless  to  a  certain  extent  the 
decay  is  checked  by  the  cleansing  action  of  attri- 
tion, while  there  is  very  little  pressure  on  the  labial 
surface  to  cause  breakage.  Thus  we  often  find 
extensive  caries  in  front  teeth,  extending  even  to 
the  pulp,  while  the  labial  surface  is  nearly,  or  quite, 
intact ;  and  this  teaches  us  a  lesson  in  treatment, 
for  if,  in  filling  front  teeth,  we  shape  the  surfaces 
treated  so  as  to  take  advantage  of  this  self-cleansing 
process,  we  shall  find  that  our  work  will  stand 
better  than  if  we  attempt  to  restore  the  original 
contour  of  the  tooth.  But  this  is  a  topic  that  I 
shall  refer  to  again,  when  the  subject  of  permanent 
fillings  is  under  consideration,  as  the  teeth  we  are 
now  treating  of  are  much  too  young  for  that  class 
of  work.  What  we  want  to  do  is  to  stop  the  decay, 
if  possible,  before  it  has  made  serious  progress, 
while  it  can  be  cut  away  with  the  chisel,  or  the 
engine  disk ;  but,  personally,  I  prefer  the  chisel  for 
this  work,  because  I  can  use  the  mirror  so  as  to  see 
better  what  I  am  doing,  and  I  have  never  yet  found 
a  disk  that  I  could  work  with  as  rapidly  as  I  can 
with  the  chisel.  This  is  a  most  admirable  method 
of  treating  a  tooth  when  the  decay  is  superficial; 
and,  if  the  surface  is  well  polished  after  cutting 
away  the  decay,  it  is  quite  as  safe,  if  not  more  so, 
than  it  can  be  with  the  best  filling  that  can  be 
made.  Unfortunately  this  treatment  is  limited  to  a 
comparatively  small  number  of  cases  ;  and  when  the 


THE    PERMANENT    TEETH.  51 

decay  is  too  deep  to  be  cut  away  without  too  much 
loss  of  substance,  the  cavity  must  be  filled.  We 
therefore  cut  away  from  the  lingual  surface  all  the 
friable,  fragile  edges  of  enamel,  and  remove  all  the 
softened  dentine,  taking  care  always  to  leave  the 
cavity  larger  inside  than  it  is  at  the  orifice.  When 
only  the  calcareous  portion  of  the  dentine  is 
destroyed,  leaving  a  cartilaginous  substance  that 
is  tough  and  firmly  attached,  it  will  do  no  harm  to 
leave  some  of  the  latter  at  the  base  of  the  cavity, 
although  every  particle  must  be  removed  from  the 
edges  that  will  be  exposed  to  the  action  of  the 
oral  fluids  after  a  filling  has  been  inserted.  This 
substance,  if  protected,  will  often  be  re-calcified, 
and  become  dense,  healthy  dentine,  forming  an 
excellent  covering  for  the  pulp ;  but  when  any  of  it 
is  left  in  the  tooth,  it  is  good  practice  to  wipe  out 
the  cavity  with  carbolic  acid  immediately  before  the 
filling  is  inserted,  care  being  taken,  of  course,  to 
dry  the  cavity  again  before  filling.  Whether  the 
acid  has  any  effect  in  stimulating  the  process  of  re- 
calcification  may  be  a  question,  but  it  certainly  acts 
to  soothe  and  comfort  an  irritable  surface  of  dentine, 
and  that  is  quite  sufficient  justification  for  its  use. 
When  we  are  satisfied  with  the  excavation,  we 
dry  the  cavity  carefully  with  some  shreds  of  amadou, 
absorbent  cotton,  or  bibulous  paper  (all  of  which  are 
used  for  this  purpose,  but  I  prefer  the  amadou,  when 
it  is  of  good  quality),  and  then  we  fill  with  gutta- 
percha, which  must  not  be  overheated,  but  just  suffi- 
ciently  warmed    to   be  compressible    between    the 


52  DENTAL    PRACTICE. 

fingers.      The   packing   should   be   done  with   fine 
instruments,  the  edges  especially  being  packed  with 
quite  as  fine  instruments  as  would  be  used  for  gold, 
all  being  well  warmed,  but  not  hot.      The  corners 
and  fissures  must  be  carefully  packed,  because  the 
use  of  a  plastic  material  offers  no  excuse  for  careless 
work ;  and  the  surface   may  be   smoothed   with  a 
warm  burnisher ;  but  if  it  cannot   be  made  quite 
smooth   in   this    way,    a    strip    of    tape    may   be 
moistened  with  chloroform  and  used  as  in  polish- 
ing ^a  metallic    filling ;    the   chloroform,    being  a 
solvent  of  the  gutta-percha,  will  leave  a  perfectly 
smooth   surface.      Such  a  filling  will   not   take  a 
quarter  of  the  time  that  we  should  be  compelled  to 
spend  in  making  and  finishing  a  filling  of  gold,  and 
it  should  be  quite  understood  that  it  is  not  expected 
to  be  permanent.     Yet,  the  work  being  done  with 
equal  care,  I  would  much  sooner  trust  the  gutta- 
percha in  these  young  mouths  than  the  gold,  and 
certainly  the  pain  during  the   operation,   and   the 
sensibility  of  the  tooth   to  thermal  changes  after- 
wards, are  all  in  favour  of  the  gutta-percha.     If  the 
gutta-percha  fails,  it  will  be  from  wearing    away, 
and  not  from  new  decay  at  the  cervical  edge,  and 
a  new  filling  can  be  inserted  in  five  minutes  without 
any  new  excavation ;  but   unless   there  is  a  large 
surface  exposed  to  wear,  the  filling  will  last  three  or 
four  years  (many  of  them  are  not  touched  again  for 
ten  or  twelve  years),  and  when  it  is  desirable  to 
renew   it,  a   gold  filling  will  have   a  much  better 
chance  than  it  would  have  had  at  first. 


THE    PERMANENT    TEETH.  53 

It  may  be  said  that  the  gold  fiUings  would  last 
too,  if  the  teeth  were  kept  clean  ;  but  we  cannot 
make  boys  and  girls  of  ten  and  twelve  years  of  age 
as  careful  as  they  will  be  at  eighteen  or  twenty, 
when  pride  in  their  personal  appearance  becomes  a 
strong  motive.  We  must  not  cease  to  preach  clean- 
liness to  them,  for  it  reminds  them  that  there  is  a 
difference  between  cleanliness  and  filthiness,  but 
our  preaching  will  not  make  all  of  them  take  as 
much  care  as  they  ought  to  take  of  their  teeth. 
This  being  the  case,  I  think  it  better  to  defer  the 
gold  fillings  to  a  period  nearer  the  time  when  we 
shall  have  the  assistance  of  personal  vanity  as  an 
incentive  to  taking  care  of  the  work  we  do  for  them. 

We  shall  often  find  teeth  that  are  more  or  less 
imperfectly  covered  with  enamel,  sometimes  from 
inherited  malformation,  and  sometimes  from  illness 
occurring  in  early  infancy,  while  the  process  of 
development  of  the  permanent  teeth  is  going  on. 
In  the  former  case  the  imperfection  will  have  com- 
menced with  the  earliest  stage  of  development  of 
the  enamel,  that  is  at  the  cutting  edge  of  the 
incisors  and  the  points  of  the  cusps  in  the  molars, 
and  it  may  extend  over  the  whole  crown  of  the 
tooth,  or,  as  is  more  frequently  the  case,  over  a 
third  or  half  of  the  tooth  (Figs.  ]8  and  19),  and  then 
the  enamel  may  be  quite  perfect  on  the  remainder 
of  the  crown.  The  defective  portion  may  be 
absolutely  without  enamel,  there  may  be  small 
detached  patches  of  enamel  affording  no  protec- 
tion to  the  tooth,  or  it  may  be  interrupted   with 


54 


DENTAL    PRACTICE. 


pits  and  jQssures,  but  still  serviceable  over  a  good 
of    the    affected    surface.      If    the   defect  is 


Figures  18. — Showing  defective  formation  of  enamel  on  two  upper  central 

incisors. 


Figure  19. — Showing  defective  formation  of  enamel  on  lower  incisors. 

owing  to  illness  in  infancy,  the  interrupted  for- 
mation may  occur  as  a  line  of  pits  across  the 
surface  of  the  tooth,  or  a  band  of  defective  thin 
enamel,  which  may  also  extend  across  the  surface 
of  an  otherwise  well-formed  tooth;  the  cutting 
edge  or  the  cusps  will  be  properly  developed,  then 
the  band  of  imperfect  formation  appears,  and  then 
the  enamel  organ  recovers  its  function,  as  the  period 
of  weakness  passes,  and  the  remainder  of  the 
crown  will  be  perfectly  covered  with  well- developed 
enamel.  (Figs.  20  and  21.)  We  sometimes  see  two 
or  three  of  these  bands  across  the  surface  of  the 
incisors,  with  well-formed  enamel  between,  marking 
periods  of  alternate  weakness  and  strength.  Defects 
of  this  nature  are  usually  confined  to  the  incisors 


THE    PERMANENT    TEETH. 


55 


and    first   molars,   though    sometimes    the    bicus- 
pids are  affected   to   a   less   degree,   which    seems 


Figure  20. — Showing  a  baud  of  defective  euamel. 


.-^^ 


iff  -^  «^     ,.*x. 


Figure  21. — Showing  alternate  bands  of  perfect  and  defective  enamel  across 
all  the  upper  front  teeth,  including  the  bicuspids. 

to  indicate  that  the  teeth  of  later  development 
are  not  so  liable  to  be  affected  by  illness.  It 
may,  however,  be  assumed  that  any  severe  illness 
occurring  during  the  first  one  or  two  years  of 
infantile  life  will  be  likely  to  affect  the  structure 
of  the  teeth,  and  the  administration  of  some  of  the 
preparations  of  lime,  known  as  phosphatic  food, 
may  be  very  beneficial  in  supplying  the  materials 
for  the  calcification  of  the  enamel. 

The  treatment  necessary  in  these  cases  of 
defective  enamel  is  to  fill  every  pit  or  fissure, 
where  the  dentine  is  exposed,  and  to  file  away  as 
much  as  possible  of  the  dentine  that  is  quite  unpro- 
tected on  the  cutting  edges  and  grinding  surfaces  of 


56  DENTAL    PRACTICE. 

the  teeth ;  but  the  use  of  the  file  and  corundum 
wheel  must  be  limited  to  the  removal  of  sharp 
points  and  thin  edges — in  short,  to  mere  protection, 
until  the  patient  is  sixteen  or  seventeen  years  of 
age,  when  a  great  deal  may  be  done  with  these 
instruments  to  improve  the  appearance  of  teeth 
which  at  first  seemed  almost  hopelessly  misshapen. 
The  bicuspids  are  quite  as  much  predisposed  to 
caries  as  the  incisors,  and  while  cavities  in  the 
sulcus  between  the  cusps  may  be  easily  and  quickly 
seen,  much  more  serious  mischief  may  be  going  on 
in  the  interstices.  Therefore  careful  examination 
with  thin  delicate  instruments,  and  with  waxed  silk, 
or  the  loosely-twisted  linen  thread  used  by  shoe- 
makers, is  necessary  to  detect  the  earliest  indica- 
tions of  disintegration  and  roughness  of  the  enamel 
on  the  approximal  surface.  I  believe  that  free' 
excision  is  the  best  treatment  for  these,  and  for 
approximal  decay  in  all  teeth,  when  the  disease  is 
superficial,  or  has  not  penetrated  so  deeply  that  to 
cut  it  away  will  injure  the  appearance  of  the  labial 
surface  of  the  tooth.  I  cannot  do  better  than  to 
borrow  from  the  late  Dr.  Arthur's  valuable  work* 
on    this    method    of    treatment,    an   illustration  of 


*  Treatment  and  Prevention  of  Decay  of  the  Teeth,  by  Eobert  Arthur, 
M.D.,  D.D.S.  J.  B.  Lippineott  &  Co.,  Philadelphia.— A  work  that  teaches 
and  strongly  urges  the  practice  of  a  different  system  of  treatment  from  that 
which  is  recommended  here  ;  but  it  is  a  book  that  should  be  read  by  every 
dental  student ;  and  if  he  is  convinced  that  the  teaching  is  sound,  the 
student  cannot  do  better  than  to  follow  the  lead  of  a  man  who  had  the 
courage  of  his  opinions,  and  consistently  operated  as  he  thought,  to  the 
lasting  benefit  of  those  who  were  fortunate  enough  to  have  had  their  teeth 
under  his  thoughtful  aud  skilful  treatmenti 


THE    PERMANENT    TEETH.  57 

the  best  way  of  making  the  V  shaped  spaces  that 
will  leave  the  surfaces  self-cleansing,  and,  therefore, 
self-protecting.  It  will  be  observed  that  the  spaces 
are  V  shaped  in  two  directions,  from  the  labial 
approximal  and  from  the  cervical  approximal  sm-- 
faces.     (Fig.  22.) 


Figure  22. — Sbowing   the  method,   approved  by  the  late  Dr.   Arthur,   of 
cutting  away  the  approximal  surfaces  of  the  teeth  for  preventing  decay. 

But  if  the  decay  has  penetrated  to  any  extent 
into  the  dentine,  the  tooth  should  be  filled,  always, 
I  think,  with  gutta-percha  at  first,  until  after  the 
constitutional  changes  at  puberty,  for  the  oral 
secretions  at  this  period  are  too  strongly  acidulated 
for  any  other  form  of  filling  to  be  safe.  The  idea 
of  the  V  shaped  space  should,  however,  be  kept  in 
mind  in  shaping  the  cavities  for  filling. 

The  canines  are  usually  more  dense  than  the 
teeth  on  either  side  of  them,  but,  nevertheless,  they 
are  often  unable  to  resist  the  effect  of  the  carious 
condition  of  a  surface  in  contact  with  them,  and 
they  must  be  treated  in  the  same  way  as  their 
neighbours. 

All  the  teeth  anterior  to  the  first  permanent 
molars  being  now  in  position,  and  the  child  being 


58  DENTAL    PRACTICE. 

twelve  years  old,  we  should  find  that  there  has  been 
a  sufficient  lengthening  out,  or  growth,  of  the  max- 
illary bones  beyond  the  first  molars,  to  make  room 
for  the  twelve-year,  or  second  permanent  molars  ; 
we  may  also  reasonably  expect  to  see  all  four  of 
these  teeth  before  the  child  is  thirteen  years  of  age. 


59 


CHAPTER    III. 


Extraction  as  a  means  of  Preventing  Decay. 

In  the  preceding  chapters  we  have  noted  the 
progress  of  dentition  until  the  second  permanent 
molars  have  appeared,  and  have  endeavoured  to 
show  that  extraction  is  an  unnecessary  and  unjus- 
tifiable operation,  except  so  far  as  may  be  absolutely 
necessary  in  order  to  permit  each  permanent 
tooth,  in  its  turn,  to  come  into  its  natural  position 
in  the  dental  arch.  But  at  this  period  of  develop- 
ment it  is  sometimes  advisable  to  remove  a  tooth 
from  each  side  of  each  jaw  for  the  conservation  of  a 
well-arranged  and  comfortable  set  of  teeth  in  after- 
hfe. 

It  now  becomes  the  duty  of  the  dentist  to  con- 
aider  well  whether  he  can  hope  to  preserve  all  the 
teeth  that  are  in  the  mouth  at  this  age.  He  must 
take  careful  notice  of  the  tendency,  if  any,  to 
approximal  decay;  and  in  considering  this  he  will  do 
well  to  remember  what  has  been  his  experience  with 
other  and  older  members  of  the  same  family.  He 
should  recall  his  experience  with  teeth  that  resem- 
bled these  in  colour,  shape,  and  density,  in  the 
mouths  of  other  young  patients  whose  teeth  he  has 


60  DENTAL    PEACTICE. 

watched  through  the  natural  changes  at  puberty ; 
and  he  should  notice  whether  his  instructions 
respecting  cleanliness  have  been  and  are  carefully 
attended  to.  He  should  see  how  the  upper  and 
lower  teeth  articulate,  and  whether  they  have  plenty 
of  room,  or  are  crowded  and  irregularly  placed  in 
the  dental  arch  ;  and,  in  short,  he  must  exercise 
all  the  power  that  teaching  and  experience  have 
given  him  to  form  a  prognosis  of  the  effect  that  the 
constitutional  changes,  now  about  to  take  place,  will 
have  upon  the  teeth  of  the  individual  case  before 
him.  He  must  not  lay  down  hard  and  fast  rules 
for  practice,  but  study  the  peculiarities  and  probabil- 
ities of  every  case  by  itself,  and  in  comparison  with 
others.  And  if  family  history  and  local  appear- 
ances indicate  that  the  teeth  will  suffer  seriously 
from  the  excessive  acidity  which  is  natural  to  the 
oral  secretions  at  this  period  of  life,  there  should  be 
no  hesitation  in  advising  the  immediate  removal  of 
the  six-year  molars,  if  the  articulation  is  normal ;  or 
the  second,  or  first  bicuspids,  if  abnormal  articula- 
tion seems  to  indicate  that  the  removal  of  these  will 
more  effectually  relieve  crowding  and  pressure. 
But  in  any  case,  the  teeth  which  are  selected  for 
extraction  should  be  opposites ;  that  is,  if  decay, 
or  defective  structure,  or  malposition,  or  space 
required,  points  to  the  extraction  of  a  molar  in  one 
jaw,  the  tooth  articulating  with  it  should  be  the  one 
to  be  extracted  from  the  other  jaw,  or  else  the  tooth 
that  has  no  antagonist  will  elongate,  and,  by  pro- 
truding like  a  wedge  into  the  gap  that  is  opposite, 


EXTRACTION  AS  A  MEANS  OF  PREVENTING  DECAY.  61 

will   prevent   the   desired   separation  of  the  other 
teeth,  as  may  be  seen  in  Fig.  23. 


Figm-e  23. — Showing  how  a  tooth  will  elongate,  and  thus  prevent  the  closing 

up  of  gaps,  when  otber  than  opposite  or  antagonizing  teeth  are  extracted 

to  reUeve  crowding. 

If  there  is  no  decided  counter-indication,  it  is 
always  preferable  to  extract  molars  for  this  purpose, 
because  we  thereby  immediately  protect  the  bicus- 
pids and  the  second  molars  from  approximal  decay. 
We  do  not  disturb  the  symmetrical  arrangemeut  of 
any  of  the  anterior  teeth  that  are  seen  by  the 
ordinary  observer ;  but,  on  the  contrary,  give  them 
room  to  correct,  of  themselves,  many  ugly  irregu- 
larities. We  also  give  space  to  the  wisdom  teeth, 
so  that  they  will  come  earlier  than  they  otherwise 
would,  and  are  more  likely  to  be  serviceable  teeth 
when  they  do  come ;  and  we  shall  have  selected  for 
removal  the  teeth  that  are  already  seriously  decayed 
in,  at  least,  eighty  per  cent,  of  the  cases  which  we 
shall  see  in  ordinary  practice. 

The  bicuspids  will  at  once  begin  to  fall  back, 
thus  isolating  themselves,  and  making  room  for 
the  canines  and  incisors  to  gain,  a  little  later,  the 
amount  of  space  that  is  so  essential  to  their  preser- 
vation.     I  have  seen  cases  where,  in  one  year,  the 


62  DENTAL    PRACTICE. 

gaps  left  by  the  extraction  of  the  molars  were  so 
filled  up  that,  in  the  upper  arch,  there  was  only 
about  the  same  space  between  the  second  bicuspid 
and  second  molar  that  there  was  between  the  bicus- 
pids, and  between  the  first  bicuspid  and  the  canine, 
and  the  incisors  were  also  perceptibly  separated ; 
and  in  the  lower  arch  the  bicuspids  had  fallen  back 
so  much  as  to  be  quite  safe  from  approximal  decay. 

Teeth  that  are  isolated  do  not  suffer  from 
approximal  decay.  I  do  not  mean  to  say  that,  if 
it  has  commenced  before  the  separation  took  place, 
it  will  not  go  on,  but  it  will  not  commence  spon- 
taneously in  a  tooth  so  situated,  except  in  cases  of 
severe  illness,  or  of  that  peculiar  condition  of  the 
oral  secretions  that  may  be  seen  when  there  is  a  rapid 
breaking  up  of  the  constitution,  either  prematurely, 
or  from  old  age,  when  no  part  of  a  tooth  seems 
exempt  from  what  has  been  termed  senile  decay. 
It  is  therefore  safe  to  say  that,  when  we  have  suc- 
ceeded in  isolating  all  the  upper  teeth,  and  the 
lower  bicuspids  and  molars,  we  have  effectually 
protected  them  from  approximal  decay. 

Some  writers  deny  that  there  is  any  falling  back 
of  the  bicuspids  after  the  molars  are  extracted,  but 
such  writers  simply  do  not  know  what  they  are 
writing  about.  I  have  watched  the  growing  up  of 
a  good  many  families  of  young  people  ;  some  of  them 
who  came  to  me  with  their  first  dental  troubles,  are 
now  men  and  women,  with  children  of  their  own. 
Many  families  have  come  under  my  care  when  the 
elder  children  were  well  on  in  their  teens,  and  the 


EXTRACTION  AS  A  MEANS  OF    PREVENTING  DECAY.    63 

younger  ones  still  in  the  nursery,  so  that  I  could 
compare  the  result  of  early  treatment.  Many  had 
been  under  the  care  of  the  best-known  dentists  in 
both  hemispheres,  and  thus  I  am  sure  that  few  men 
have  had  a  better  opportunity  to  judge  of  the  results 
of  different  systems  of  treatment.  I  have  extracted 
the  molars  in  a  good  many  cases,  and  I  have  never 
yet  seen  a  case  where,  if  they  were  extracted  at  the 
proper  time,  the  bicuspids  failed  to  move  backwards, 
and  so  make  for  themselves  and  the  front  teeth 
more  room.  I  have  seen  a  few  cases  where  extrac- 
tion of  the  molars  was  not  a  sufficient  protection, 
but  I  have  never  seen  a  case  where  I  regretted 
having  adopted  this  treatment,  and  I  have  seen 
many  cases  where,  from  a  feeling  of  confidence  that 
I  could  do  without  it,  I  have  not  recommended  it, 
and  would  have  given  anything  afterwards  if  I 
could  have  changed  my  plan  of  practice.  One 
instance  of  this  nature  I  can  recall,  the  daughter  of 
a  medical  man,  one  of  my  most  intimate  friends. 
At  twelve  years  of  age  she  was  a  strong  healthy 
girl,  and  had  teeth  that  seemed  capable  of  resisting 
anything,  and  yet,  before  she  was  eighteen  years 
old,  the  bicuspids  and  molars  were  decayed  on  both 
approximal  surfaces ;  there  were  dead  pulps  in  three 
of  them ;  and  although  she  was  only  about  a  month 
in  every  year  absent  from  home,  when  she  could  not 
consult  me,  she  had  suffered  so  much  pain  that  two 
of  these  teeth  had  been  extracted.  This  was  a  case 
where  the  teeth  were  dense  and  hard  in  structure, 
and  well  covered  with  enamel.     They  were  yellowish 


64  DENTAL    PRACTICE. 

white  in  colour,  and  short  and  broad  in  form, 
having,  in  fact,  all  the  characteristics  that  we  look 
upon  as  indicating  the  best  type  of  teeth.  The 
young  lady  was  careful  with  them,  and  came  often 
to  have  them  examined,  and  when  the  first  indica- 
tions of  approximal  decay  appeared,  I  filled  the 
cavities  (mere  pin  holes)  with  gold,  thinking  that  if 
it  was  suitable  for  any  teeth  it  was  so  for  these. 
I  know  the  work  was  well  done,  but  the  decay  went 
on  notwithstanding  all  this,  and  I  am  sure  that  it 
was  only  want  of  space,  at  the  time  when  isolation 
would  have  absolutely  prevented  decay,  which  caused 
all  the  trouble.  If  I  had  extracted  the  first  molars 
as  soon  as  the  second  molars  appeared,  there  would 
have  been  no  occasion  for  any  approximal  fillings 
up  to  the  present  time  ;  and  when  she  was  eighteen, 
the  fact  that  four  teeth  had  been  extracted  would 
have  been  perceptible  only  to  a  professional  eye. 

The  second  molars  are,  of  course,  perfectly 
isolated  from  the  moment  of  the  extractions,  and 
approximal  decay  is  practically  impossible,  but  the 
sulci  of  the  grinding  and  buccal  surfaces  are  liable 
to  suffer. 

Prominent  canines  are  always  unsightly,  but 
they  will  generally  right  themselves  after  the 
extraction  of  the  molars.  Unless  they  are  much 
worse  than  those  shown  in  Fig  24,  there  is  no 
need  for  mechanical  assistance  to  straighten  them. 
The  lower  canine  on  the  right  side  may  not  come 
quite  into  its  place,  for  the  lower  teeth  do  not 
change  their  position  quite  so  readily  as  the  upper 


EXTRACTION  AS  A  MEANS  OF  PREVENTING  DECAY.  65 

ones,   but   it   is   doubtful   if    even   that   will  need 
artificial  pressure  to  get  it  into  place.     In  this  case 


Figure  24. — Showing  very  prominent  canines,  age  13. 

the   molars  were   extracted   immediately  after   the 
impressions   were   taken.* 

Dr.  Arthur's  method  of  preventing  decay,  by 
cutting  away  a  portion  of  the  mesial  and  distal 
surface  of  every  tooth,  may,  perhaps,  be  as  effective 
as  extraction  of  the  molars.  I  confess  I  have  never 
tried  it  to  the  extent  that  he  recommends,  for  I 
think  it  is  better,  if  possible,  to  have  twenty-eight 
teeth,  well  shaped  and  well  covered  with  enamel, 
than  to  have  thirty-two,  with  a  slice  taken  off  each 
side  of  every  one  of  them,  except  the  wisdom  teeth, 
from  which  it  will  only  be  necessary  to  cut  away 
the  mesial  surface.  The  illustrations,  Figs.  25,  26 
and  27,  will  give  a  good  idea  of  the  two  systems  of 
treatment.  Figs.  26  and  27  are  from  casts  taken 
from  the  mouth  of  a  young  lady  of  sixteen,  the 
molars  having  been  extracted  when  she  was  twelve 

•  I  have  seen  thifi  case  again,  six  months  after  the  extractions,  and 
the  lower  canine  is  now  clear  of  the  upper  lateral,  and  will  come  quite  into 
the  arch. 

E 


66  DENTAL    PEACTICE. 

years  old.    It  will  be  seen  that  the  wisdom  teeth  are 
already  in  position,  and  that  they  are  well-developed 


Figure   25. — Another  illustration  from  the  work  of  Dr.  Arthur,  showing 
only  twelve  teeth  in  the  upper  jaw,  but  giving  a  good  idea  of  his  method. 

teeth.  This  is  by  no  means  an  exceptional  case. 
I  could  in  time  make  a  collection  of  a  large  number 
of  similar  results  from  the  extractions  of  the  molars, 
but  one  is  sufficient  to  show  what  is  possible. 
There  is,  in  truth,  no  reason  why  wisdom  teeth 
should  not  be  quite  as  serviceable  as  any  others 
in  the  mouth,  although  this  is  not  usually  the  case 
with  wisdom  teeth,  because  when  all  the  others  are 
in  the  mouth,  or  when  one  has  been  extracted  here 
and  there  without  a  specific  plan,  and  the  gaps 
remain,  there  is  no  room  for  the  teeth  that  are 
latest  in  formation,  and  thus  their  development  is 
interfered  with,  or  their  eruption  is  retarded.  In 
the  one  case,  therefore,  they  will  be  malformed  or 
misplaced,  and  in  the  other  they  will  be  decayed 
before  they  even  come  into  a  position  to  be  of  any 
service,  or  to  be  treated  to  prevent  decay.     There 


EXTRACTION  AS  A  MEANS  OF  PREVENTING  DECAY.  67 

can  be  no  doubt  that  civilisation  has  so  fined 
down  the  human  face,  that  the  maxillary  bones  of 
Europeans  and  Americans  are  much  smaller  than 


Figure  26. 


Figure  27. 

FigureB  26  and  27. — Showing  the  condition  of  the  upper  and  lower  teeth  in 

the  mouth  of  a  young  lady  at  sixteen  years  of  age,  the  six  year  molars 

having  been  extracted  about  four  years. 

those  of  the  savage  races  that  still  inhabit  the 
earth;  and,  if  there  is  anything  in  the  theory  of 
evolution,  this  is  easily  accounted  for.     The  heavy 


68  DENTAL    PEACTICE. 

animal  character  which  is  given  to  the  face  by  a 
large  development  of  the  maxillary  bones  is  not  a 
type  of  beauty  that  is  much  admired  in  civilised 
life,  consequently  it  becomes  fined  down  by  the 
process  of  natural  selection.  Again,  civilisation 
leads  to  good  cookery,  and  this  to  diminished 
labour  for  the  bones  and  muscles  that  are  called 
into  action  in  mastication ;  and  the  theory  of  evolu- 
tion is,  that  the  organs  which  are  called  into  greater 
activity  by  new  conditions  of  life  receive  increased 
development,  while  those  which  are  of  diminished 
importance  become  dwarfed  and  rudimentary.  Thus 
it  is  easily  seen  that,  after  centuries  of  civilisation 
and  good  cookery,  the  organs  of  mastication  are 
not  likely  to  be  so  well  developed  as  those  of  the 
savage,  who  does  not  hang  his  meat  until  it 
becomes  tender,  and  is  satisfied  with  rude  cookery, 
or  none  at  all.  The  maxillary  bones  have  become 
smaller  in  these  days  of  luxury  and  good  living, 
and  the  wisdom  teeth  suffer  from  want  of  room, 
so  that  we  often  find  them  misshapen,  or  so  much 
smaller  than  other  teeth,  that  they  might  be  said 
to  be  rudimentary ;  or  else  we  find  them  coming 
slowly  and  painfully  into  position,  protruding  one 
cusp  through  the  gum,  and  making  little  or  no  more 
progress  for  months,  and  often  for  years,  because 
there  is  no  room  for  them  to  advance. 

It  is  unnecessary  to  explain  to  the  dental  student 
that  the  soft  tissues  do  not  adhere  to  the  enamel  of 
a  tooth,  and  that  if  one  cusp  has  found  its  way 
through  the  gum,    the   soft  tissues  must  form  an 


EXTRACTION  AS  A  MEANS  OF  PREVENTING  DECAY.  69 

open  pouch  around  the  remainder  of  the  crown  of 
that  tooth.  Therefore,  if  this  condition  of  things 
exists  for  any  considerable  period,  the  secretions 
and  particles  of  food  which  find  their  way  into  the 
mouth  of  the  pouch  must  have  an  injurious  effect 
upon  the  tooth,  and  when  it  finally  emerges  from 
the  gum,  it  is  likely  to  be  with  a  softened  and 
chalky  condition  of  enamel,  at  least,  if  not  with  its 
dentine  also  affected.  Thus  wisdom  teeth  have  got 
a  reputation  for  coming  late,  giving  much  pain  in 
the  process,  and  going  early;  but  if  they  have 
a  fair  chance  given  them  in  time  to  benefit  by 
it,  there  is  no  reason  why  they  should  not  be 
as  good  as  any  other  teeth,  and  quite  make  up  for 
the  loss  of  the  first  molars,  if  that  can  be  called  a 
loss  which  we  have  shown  to  be  a  gain  to  every 
part  of  the  dental  arch. 

The  period  when  isolation  is  so  essential  to  the 
preservation  of  the  anterior  teeth  being  past,  the 
wisdom  teeth  serve  another  important  use,  for  they 
press  the  second  molars  forward  and  gradually  close 
up  the  spaces,  until  the  mouth  presents  the  appear- 
ance seen  in  the  last  illustration,  of  a  remarkably 
good  and  regular  set  of  teeth. 

Some  of  our  best  men  tell  us  that  extraction 
should  never  be  resorted  to  until  we  have^^done 
everything  in  our  power  to  preserve  all  the  teeth. 
This  is  a  well-sounding  theory,  but  practically  timid, 
and  working  harm  instead  of  good  ;  for  when  we 
have  tried  it,  and  have  found  our  efforts  ineffectual, 
as  we  surely  shall  find  them,  if  the  conditions  of 


70  DENTAL    PRACTICE. 

weakness  of  structure  and  excessive  acidity  exist  in 
conjunction  J  it  will  be  too  late  to  try  back,  for  the 
period  when  the  greatest  benefit  could  be  gained 
from  extractions  will  have  passed,  and  permanent 
gaps  will  remain  in  the  mouth  to  remind  us  con- 
stantly of  our  timidity  and  failure. 

The  extraction  of  the  molars  is  always  a  difficult 
and  painful  operation,  even  when  they  are  com- 
paratively strong,  and  we  may  reasonably  hope  to 
get  all  the  roots  at  once  ;  but  when  they  are 
seriously  decayed  and  broken  down,  the  difficulty 
is  greatly  increased,  and  both  patient  and  operator 
must  needs  have  plenty  of  nerve  to  contemplate 
the  operation  without  the  aid  of  anaesthesia.  The 
certainty  that  there  will  be  no  suffering  from  the 
operation,  except  the  soreness  that  must  imme- 
diately follow,  helps  the  patient  wonderfully  in 
making  up  the  mind  to  submit  to  what  often  seems, 
to  a  child,  a  piece  of  wilful  cruelty  on  the  part  of  the 
dentist,  for  the  child  cannot  be  expected  to  see  the 
necessity  which  is  so  apparent  to  the  professional 
eye.  And  the  same  certainty  helps  the  operator 
too ;  for  although  he  may  have  to  struggle  with 
rigidity  of  muscle,  and  obscurity  of  view  from  the 
flow  of  blood,  it  is  a  help  to  him  to  know  that  he 
is  not  inflicting  pain,  and  he  is  not  discouraged  if 
his  first  effort  to  remove  an  obstinate  fang  results 
in  failure.  Once  undertaken,  the  work  must  be 
thorough.  All  fragments  of  roots  must  be  removed, 
even  though  it  be  necessary  to  cut  through  gum 
and  alveolus  to  accomplish   it ;   indeed,  if  it   will 


EXTRACTION  AS  A  MEANS  OF  PREVENTING  DECAY.  71 

facilitate  the  extraction  of  a  troublesome  root,  one 
should  never  shrink  from  cutting  through  the 
alveolus,  for  it  only  takes  away  what  would  be 
removed  afterwards  by  the  natural  process  •  of 
absorption. 

A.S  I  have  observed,  it  is  most  important  that 
all  roots  and  fragments  of  roots  should  be  removed, 
and  although  there  may  be  nothing  new  in  my 
suggestions,  it  may  not  be  out  of  place  to  give 
some  general  instructions  for  this  operation.  If 
the  teeth  are  strong,  no  instrument  can  be  better 


Figure  28. — Lower  molar  forcep. 


Figure  29.— Upper  molar  forcep.     (a)  Right  side.     (6)  Left  side. 

adapted  for  their  extraction  than  the  ordinary  forms 
of  molar  forceps  of  English  make — Fig.  28  for 
lower  molar  of  either  side,  and  Fig.   29   for  right 


72 


DENTAL    PEACTICE. 


and  left  upper  molars.  But  when  the  teeth  are 
much  broken  down,  I  prefer  the  stump  forceps  of 
American  make.  The  strong  beaks  of  the  right- 
angle  instrument,  Fig.  30,  for  the  right  side,  and 
Fig.  31,  for  the  left  side,  lower  jaw,  are  most 
useful,  giving  one  the   power,  if  necessary,  to  cut 


Figure  30. — Lower  stump  forceps.    Eight  side. 


Figure  31. — Lower  stump  forceps.    Left  side. 


Figure  32. — Elevator. 

through  the  alveolus  and  remove  the  posterior  root, 
and  then  with  the  elevator,  Fig.  32,  to  push  back 
the  anterior  root,  so  that  it  may  be  grasped  by  the 


EXTRACTION  AS  A  MEANS  OF  PREVENTING  DECAY.  73 

mesial  and  distal  surfaces  with  the  thin  flat  beaked 
instrument,  Fig.  33,  made  from  my  own  design  ; 
and  the  bayonet- shape,  Fig.  34,  for  upper  stumps. 


Figure  33. — Thin  flat  beaked  forcep,  for  grasping  a  loose  root  by  mesial  and 
distal  surfaces. 


Figure  34. — Upper  stump  forcep. 

These  instruments  enable  one  to  remove  stumps 
with  more  certainty,  and  actually  with  less  lacera- 
tion of  surrounding  tissues,  than  the  ordinary 
stump  forceps  of  English  make,  which  are  not 
strong  enough  in  the  beak  for  the  purpose,  and 
always  bend  or  break  in  my  hands. 

If  it  is  decided  to  make  use  of  an  anaesthetic, 
the  assistance  of  a  surgeon  should  be  considered 


74  DENTAL    PEACTICE. 

indispensable.  No  dentist  should  ever  attempt  to 
give  any  of  the  preparations  used  for  this  purpose 
without  such  assistance.  A  man  cannot  do  two 
things  at  the  same  moment,  and  do  both  of  them 
well,  and  although  a  dentist  may  understand  how 
to  administer  an  anaesthetic  quite  as  well  as  a 
surgeon,  and  how  to  watch  its  effects,  he  cannot  do 
this  if  his  whole  attention  is  directed  to  his  opera- 
tion, as  it  should  be,  to  make  success  a  certainty. 
The  selection  of  the  anaesthetic  to  be  used  would, 
therefore,  rest  with  the  surgeon,  and  it  is  unneces- 
sary for  me  to  do  more  than  allude  to  the  various 
preparations  employed  for  this  purpose,  which  I 
shall  do  from  the  purely  practical  point  of  view  of 
a  busy  dentist. 

Chloroform  is  the  most  powerful  agent  for  pro- 
ducing insensibility  to  pain.  It  is  not  disagreeable 
to  the  patient,  and  causes  only  a  moderate  amount 
of  excitement  during  inhalation.  If  I  were  pre- 
paring the  mouth  of  a  strong  man  for  artificial 
teeth,  or  if  such  a  patient  required  anaesthesia  for 
even  a  much  shorter  operation  than  that,  I  should 
consider  that  nothing  else  would  do  so  well,  and 
that  nothing  could  be  better.  If  I  were  taking  an 
anaesthetic  myself,  I  should  prefer  chloroform  to 
anything  else. 

Ether  is  probably  more  reliable  as  a  safe  agent 
for  producing  anaesthesia  for  very  prolonged  opera- 
tions. Women  take  it  very  quietly  as  a  rule,  but  it 
is  very  troublesome  in  the  case  of  a  strong  man,  as 
it  is  pungent  and  disagreeable  to  inhale,  causing  a 


EXTRACTION  AS  A  MEANS  OF  PREVENTING  DECAY.  75 

feeling  of  suffocation,  and  generally  a  good  deal  of 
excitement  and  struggle  to  resist  the  approach  of 
insensibility,  so  that  it  is  followed  by  exhaustion 
and  depression  on  the  part  of  the  patient,  and 
certainly  by  a  very  considerable  amount  of  fatigue 
on  the  part  of  all  who  have  been  engaged  in  the 
operation. 

Chloroform  and  ether  are  sometimes  combined 
with  a  certain  proportion  of  alcohol,  and  adminis- 
tered in  that  form ;  but  I  have  not  had  any  experi- 
ence  of  this  combination.  Chloroform  is  also 
frequently  given  as  a  preparation  for  ether.  In 
such  a  case  the  former  is  inhaled  until  after  the 
stage  of  excitement  is  passed,  and  then  ether  is 
substituted  for  completing  and  maintaining  insensi- 
bility. This  method  avoids  the  disagreeable  effects 
of  ether,  and  the  supposed  danger  of  chloroform, 
and  is  certainly  preferable  to  ether  alone,  inasmuch 
as  it  saves  the  patient  the  exhaustion  which  so 
frequently  follows  the  use  of  that  agent  by  itself; 
but  it  does  not  appear  to  be  very  generally  used, 
although  I  am  unaware  of  any  objection  to  it.  Why 
women  take  ether  so  much  more  quietly  than  men, 
I  cannot  attempt  to  explain  ;  but  every  one  who  has 
had  experience  with  anassthetics  is  well  aware  of  the 
fact.  Both  cloroform  and  ether  may  be  used  for 
children  with  almost  perfect  safety,  as,  whatever 
may  be  the  danger  to  adults  from  either  of  these 
agents,  it  is  certain  that  there  is  very  little  to 
children.  One  of  the  disagreeable  after-results  from 
anaesthesia  is  sickness,  which  almost  always  follows, 


76  DENTAL    PRACTICE. 

if  there  is  any  undigested  food  in  the  stomach.  It 
is  therefore  always  best  to  make  the  appointment 
for  these  operations  early  in  the  morning,  when  the 
stomach  is  absolutely  empty. 

Several  other  preparations  have  been  recom- 
mended since  the  discovery  of  chloroform,  but  none 
of  them  has  come  into  general  use.  I  have,  how- 
ever, had  a  good  deal  of  experience,  in  the  last  two 
years,  with  ethidene  dichloride,  and  I  am  so  far 
greatly  pleased  with  it,  for  children  especially.  It 
is  not  so  potent  as  either  chloroform  or  ether,  but  it 
is  quite  sufficient  to  make  any  child  absolutely 
insensible  to  pain  long  enough  for  the  extraction 
of  the  four  molars,  and  that  is  the  most  serious 
operation  the  dentist  will  have  to  perform  for  a 
child.  It  is  not  more  disagreeable  to  inhale  than 
chloroform  ;  is  administered  in  precisely  the  same 
way  as  the  latter  ;  and  is  said  to  be  quite  as  safe  as 
ether. 

Nitrous  oxide,  or  what  is  commonly  called 
"  gas,"  is  the  anaesthetic  most  frequently  asked  for, 
and  when  it  is  in  constant,  daily  and  hourly  use,  it 
is  undoubtedly  the  best  agent  for  producing  insensi- 
bility for  dental  operations.  But  as  the  chief 
business  of  the  dentist  is  the  preservation  of  the 
teeth,  it  cannot  be  expected  that  he  will  be  con- 
stantly engaged  in  extracting  them.  Yet,  as  the 
apparatus  required  for  the  gas,  even  in  its 
compressed  form,  is  too  bulky  for  the  surgeon  to 
carry  about  with  him,  the  dentist  is  expected  to  be 
provided  with  it,  and  it  must  often  happen  that  it 


EXTRACTION  AS  A  MEANS  OF  PREVENTING  DECAY.  77 

will  not  be  in  daily,  or  even  weekly,  requisition  ; 
and  certainly  it  is  not  improved  by  disuse.  The 
insensibility  produced  by  "  gas  "  is  very  transient, 
and,  if  there  is  any  difficulty  or  delay  in  the  opera- 
tion, the  patient  will  recover  consciousness,  and  feel 
the  pain  as  though  no  attempt  had  been  made  to 
avoid  it,  for,  unlike  other  anaesthetics,  the  return  of 
consciousness  is  not  gradual,  but  sudden.  It  is  not, 
therefore,  and  never  will  be,  a  favourite  anaesthetic 
with  those  dentists  who  are  cautious  enough  to 
have  always  the  assistance  of  a  surgeon  when 
anaesthesia  is  required ;  but  used  as  it  is  in  some  of 
the  larger  towns  in  the  United  States,  nothing  can 
be  better.  A  well-qualified  man,  with  such  assist- 
ants as  may  be  necessary,  makes  a  specialty  of 
extracting  teeth,  and  does  nothing  else.  He  does 
not  even  call  himself  a  dentist,  and  will  not  examine 
a  mouth  for  the  cause  of  pain,  or  give  advice,  but 
simply  extracts  the  tooth  that  he  is  asked  to 
extract ;  thus  making  a  previous  consultation  of  a 
practical  dentist  necessary  to  any  one  who  is  in  any 
degree  doubtful  of  the  operation  required.  He 
gives  tbe  "gas"  in  every  case,  and  it  is  made  on 
the  premises,  fresh  every  day.  Thus  the  apparatus, 
and  all  the  appliances,  are  always  in  order,  until 
they  are  worn  out ;  and  new  fittings  are  always  in 
readiness  to  replace  those  which  are  found  defec- 
tive or  useless.  He  becomes  wonderfully  expert, 
even  to  the  extent  of  making  a  complete  clearance 
of  a  mouth — when  the  preparation  of  the  mouth  for 
artificial  teeth  makes  such  an  operation  necessary — 


78  DENTAL   PEACTICE. 

without  renewing  the  administration  of  the  gas. 
Dr.  Slocum,  of  the  Cooper  Institute,  in  New  York, 
showed  me,  on  his  register,  the  record  of  several 
cases  where  he  had  extracted  the  remains  of  twenty- 
five  teeth  without  renewing  the  inhalation,  and  also 
the  acknowledgment  of  the  patients,  signed  after 
the  operation,  that  no  pain  had  been  felt.  Thus, 
such  a  specialist  becomes  an  invaluable  assistant  to 
the  practical  dentist,  who  would  gladly  send  all  his 
cases  for  extraction,  or  go  with  his  patients,  to  a 
man  who  will  do  this  disagreeable  work  so  well,  so 
safely,  and  with  so  little  trouble.  Dr.  Slocum  had 
administered  the  gas  in  over  100,000  cases,  without 
an  accident,  when  I  saw  him  in  1879 ;  therefore  it 
may  be  said  that  the  danger  from  anaesthesia  is 
reduced  to  the  minimum  degree,  when  it  can  be 
managed  in  this  way. 

When  the  necessity  for  the  extraction  of  the 
molars  is  admitted,  there  ought  not  to  be  any  doubt 
about  the  best  time  to  do  it ;  but  it  appears  that 
there  is,  apparently,  a  very  considerable  diversity 
of  opinion  on  this  point, — some  dentists  advising 
their  removal  at  the  age  of  ten,  and  others  at 
fourteen.  The  fact  is,  we  must  not  be  governed  by 
any  strict  rule  as  to  age,  but  rather  by  development, 
which  may  range  over  the  whole  of  the  four  years 
that  lie  between  the  advocates  of  early  and  late 
extraction.  The  object  being  to  gain  room  for  the 
teeth  to  be  saved,  we  should  surely  choose  the  time 
when  the  gain  is  greatest,  and  if  we  extract  before 
the  second  molars  appear  we  shall   stop  a  certain 


EXTRACTION  AS  A  MEANS  OF  PREVENTING  DECAY.  79 

amonnt  of  growth,  and  therefore  lose  so  much 
space  ;  while,  on  the  other  hand,  if  we  wait  long 
after  the  second  molars  are  in  position,  we  may 
certainl}^  gain  a  little  more  space  from  the  develop- 
ment of  the  wisdom  tooth,  which  would  he  making 
rapid  progress  ;  but  we  risk  more  than  we  gain,  for 
there  is  danger  that  decay  may  make  serious  pro- 
gress on  the  approximate  surfaces  of  the  bicuspids, 
while  we  are  waiting  for  a  small  gain  in  growth, 
which,  after  all,  is  not  needed,  because  the  space 
gained  by  the  extraction  of  the  molars  is  usually 
quite  enough.  It  appears,  therefore,  that  the  best 
time  for  extraction  is  immediately  after  the  erup- 
tion of  the  twelve-year  molars.  The  chief  argument 
for  deferring  the  extraction  to  the  fourteenth  year 
is  the  supposed  tendency  of  the  second  molars  to 
tip  forward  out  of  the  perpendicular  position,  there- 
by diminishing  their  usefulness  as  grinding  teeth. 
This  argument,  however,  is  based  on  unsubstantial 
grounds,  for,  practically,  the  tipping  does  not  take 
place,  and  is  not  likely  to,  because,  if  anything  is  to 
cause  tipping,  it  must  be  the  development  of  the 
wisdom  tooth  ;  and  as  we  cannot  suppose  that  the 
roots  of  the  second  molar  will  be  quite  fully  formed 
at  the  time  of  its  eruption,  we  should  have  the 
pressure  of  the  wisdom  tooth,  which,  at  this  time, 
would  have  no  roots  at  all,  in  just  the  position  we 
should  wish  it  to  be  to  move  the  second  molar 
bodily  forward.  But  if  we  wait  until  the  roots  are 
fully  formed,  and  the  wisdom  tooth  also  further 
advanced  in  developement,  we  shall  have  the  pres- 


80 


DENTAL    PBACTICE. 


sure   in    a   position    mucli    more    likely   to    cause 
tipping,   thus  : 


Figure  35. 


Figure  36. 


Figures  35  and  36. — Showing  how  the  pressure  of  a  wisdom  teeth  may  act 
upon  the  twelve  year  molars  at  different  stages  of  development. 

It  will  be  wrong  to  suppose  that  extraction  of 
the  molars  will  always  prevent  decay  on  the 
approximal  surfaces  of  the  anterior  teeth,  for  in 
some  cases  it  will  have  commenced  before  the  time 
has  arrived  for  extraction ;  and  in  other  cases,  the 
wisdom  teeth  will  have  come,  and  all  the  spaces  will 
be  closed  up,  before  the  period  of  excessive  acidity 
has  passed.  But  even  in  these  cases  of  failure  to 
obtain  a  perfectly  satisfactory  result,  we  shall  have 
the  consolation  of  feeling  that,  without  the  addi- 
tional space,  no  filling  could  have  effectually 
checked  the  progress  of  decay,  and  we  should  have 
lost  more  teeth  in  the  end.  We  must  not  relax  our 
watchfulness,  and,  if  decay  has  commenced  before 
the  extractions,  we  ought  to  discover  it  before  it  has 
made  serious  progress,  and  take  care  to  stop  its 
ravages.  As  I  have  stated  before,  the  chisel  and 
the  engine  disk  are  to  be  relied  on  for  removing 
superficial  decay  ;  but  if  the  cavity  is  so  deep  that 
the  appearance  of  the  tooth  will  suffer  from  cutting 
it   away,    a  filling  is   the  best  remedy.     The   only 


EXTBACTION  AS  A  MEANS  OF  PREVENTING  DECAY.  81 

question  is,  what  material  to  use  ;  and,  although 
general  rules  are  unreliable,  we  shall  err  on  the 
right  side,  if  we  err  at  all,  by  continuing  the  gutta- 
percha fillings  until  the  patient  is  quite  sixteen 
years  of  age. 


Figure  37. — Sbowing  upper  teeth  of  boy  at  sixteen  years  of  age,  the  molars 
having  been  extracted  at  twelve. 


Figr.ro  38. — Showing  lower  teeth  of  the  same. 

Figs.  37  and  38  show  the  present  condition  of  the 
mouth  of  a  young  gentleman  sixteen  years  of  age, 

F 


82  DENTAL    PRACTICE. 

inheriting  delicate  teeth  from  father  and  mother, 
both  of  them  having  been,  one  may  say,  all  their 
lives  in  the  dentist's  hands,  with  the  result  that,  in 
the  father's  case,  enough  teeth  remain  to  perform 
their  various  functions  with  a  tolerable  degree  of 
satisfaction,  though  every  tooth  is  filled  in  one  or 
more  places,  and  many  of  them  are  restorations, 
with  but  little  of  the  original  structure  left.  In  the 
case  of  the  mother,  the  restorations  have  taken  a 
still  more  prosthetic  form.  Educational  claims,  and 
the  needed  relaxations  in  the  holiday  time,  have 
hitherto  prevented  anything  like  an  attempt  to 
replace,  with  any  more  permanent  work,  the  gutta- 
percha fillings,  which  still  protect  the  teeth  in  this 
mouth.  The  two  upper  second  molars,  standing  in 
the  place  of  the  first,  have  gold  fillings  in  the 
grinding  surfaces,  but  all  the  rest  are  much  worn, 
though  still  serviceable  gutta-percha  fillings.  The 
teeth  are  nowhere  more  decayed  now  than  they  were 
four  years  ago,  when  the  first  molars  were  ex- 
tracted ;  but  it  is  easy  to  see  that  if  an  attempt 
had  been  made  to  retain  all  the  teeth,  they  would 
have  given  endless  trouble,  with  certain  loss  of 
some  of  them  before  the  wisdom  teeth  were  all 
erupted,  and  this,  probably,  when  it  would  have 
been  too  late  to  hope  for  the  present  symmetrical 
arrangement. 

To  those  who  would  argue  that  extracting  the 
molars  is  unjustifiable,  because  it  is  taking  alarm 
without  reasons  of  established  certainty ;  that  the 
decay  might  not,  after  all,  be  serious,  and  be  per- 


EXTRACTION  AS  A  MEANS  OF  PREVENTING  DECAY.  83 

fectly  under  control  with  all  the  teeth  in  the  mouth; 
or,  if  the  later  condition  of  the  mouth  showed  that 
the  prognosis  had  been  correct,  that  it  was  a  mere 
coincidence,  and  not  to  be  regarded  as  of  importance 
in  the  treatment  of  other  cases ;  or,  that  the  decay 
is  so  surely  from  inherent  defects  in  the  teeth,  that 
if  the  secretions  are  acid,  the  decay  will  go  on  all 
the  same,  whether  more  space  is  given  or  not ;  I 
would  call  attention  to  the  cases  which  every  practi- 
tioner must  have  seen,  where  the  molars  have  been 
extracted  on  one  side  of  the  mouth,  and  left  in  posi- 
tion on  the  other  side.  Such  cases  are  common 
enough.  The  old  ideas  that  extraction  is  the  only, 
or  at  least  the  quickest,  way  to  relieve  pain ;  that 
teeth,  especially  the  teeth  of  young  people,  are  not 
worth  a  lot  of  trouble  and  consideration;  that  the 
cheapest  way  is  to  "  get  it  out,"  or  that  there  is  no 
time  for  anything  else ;  or  any  of  the  reasons,  or 
want  of  reasons,  that  lead  to  hap-hazard  extraction, 
are  not  yet  quite  extinct ;  and  it  cannot  but 
occur  in  every  man's  practice,  that  he  will  see 
a  mouth  where  upper  and  lower  molars  have 
been  extracted,  at  something  near  the  right  age, 
on  one  side  of  the  mouth,  and  the  other  side 
has  not  been  similarly  treated.  It  seems  to  me 
that  one  has  but  to  see  such  a  case  to  be  convinced 
of  the  advantage  of  extracting  some  teeth  to  prevent 
decay  in  all.  We  shall  find  that  on  the  side  where 
space  has  been  given  at  the  right  time,  the  teeth 
are  in  much  better  condition  than  they  are  on  the 
other  side.     They  may  not  have  escaped  decay,  but 


84 


DENTAL    PEACTICE. 


they  will  not  be  so  seriously  decayed,  and  in  all 
respects  except  space,  the  conditions  will  be  similar 
on  both  sides  of  the  mouth.  The  teeth  are  developed 
in  pairs,  and  whatever  affects  the  structure  of  one  is 
likely  to  affect  its  twin  brother  on  the  other  side  of 
the  mouth.  The  secretions  will  be  the  same  on 
both  sides,  and,  therefore,  if  there  is  a  tendency  to 
decay  on  one  side,  we  may  look  for  the  same  thing 
on  the  other ;  and  if  we  find  that  on  the  side  where 
an  upper  and  a  lower  tooth  have  disappeared  at  so 
nearly  the  same  time,  that  the  filling  up  of  the  gaps 
by  change  of  position  of  the  other  teeth  is  about 


Figure  39. — Showing  the  effect  of  extracting  the  six  year  molars  on  one  side 
of  the  mouth,  and  neglecting  to  do  so  on  the  other  side. 


equal,  there  is  little  or  no  decay,  while  on  the  other 
side,  where  nothing  has  been  extracted,  all  the  teeth 
are  more  or  less  seriously  affected  by  caries,  we  must 
conclude  that  the  additional  space  has  been  a  cause 


EXTKACTION  AS  A  MEANS  OF  PREVENTING  DECAY.  85 

of  the  difference  in  the  health  of  the  two  sides  of 
the  mouth.  Such  a  case  is  represented  in  Fig.  39, 
the  model  having  been  taken  from  the  mouth  of 
a  strong  healthy  young  man  of  one  or  two  and 
twenty  years  of  age,  heir  to  a  title,  accustomed  all 
his  life  to  the  comforts  which  wealth  can  give, 
brought  up  in  the  country,  not  over  studious,  and 
fond  of  out- door  exercise  and  country  sports.  He 
had  kept  out  of  the  dentist's  hands  until  he  got 
toothache  at  school,  and,  in  accordance  with  school 
practice,  "had  it  out";  that  is,  had  an  upper 
and  a  lower  molar  extracted  on  the  right  side, 
while  the  corresponding  teeth  on  the  left  side,  not 
having  ached,  were  "  stuffed."  After  this  he  again 
kept  clear  of  the  dentists  until  he  was  past  sixteen, 
when  he  came  into  my  hands.  I  thought  it  was 
too  late  then  to  extract  on  the  left  side,  but  I 
am  convinced  now  that  it  would  have  been  better  if 
I  had  done  so,  even  if  the  gaps  did  not  quite  close 
up,  for,  as  will  be  seen,  every  tooth,  except  the 
wisdom  tooth,  on  that  side,  together  with  the  central 
and  lateral  incisors  on  the  right  side,  have  been 
filled  on  both  approximal  surfaces,  and  the  molars 
and  one  of  the  bicuspids  on  the  grinding  surfaces. 
One  central  incisor  is  dead,  and  has  been  filled  into 
the  root,  and  the  first  molar  has  been  treated  in  the 
same  manner.  Probably  the  incisors  were  already 
decayed  when  the  two  molars  on  the  right  side  were 
extracted ;  but  after  that  operation  no  other  teeth  on 
that  side  were  affected  by  caries,  and  at  the  present 
time  the  canine,  two  bicuspids,  and  two  molars  are 


86  DENTAL    PRACTICE  = 

perfectly  sound.  I  cannot  imagine  a  more  con- 
clusive proof  of  the  advantage  of  extracting  certain 
teeth  for  the  preservation  of  the  others  than  this  ; 
but  I  doubt  whether  this  view  of  the  subject  was  in 
the  mind  of  the  operator  when  he  removed  the  two 
teeth. 


87 


CHAPTER   IV. 


Irregularities. 

After  the  molars  are  extracted,  the  gain  of  addi- 
tional room  should  be  at  once  taken  advantage  of, 
if  any  considerable  change  is  to  be  made  in  the 
position  and  articulation  of  the  teeth ;  and  if  extrac- 
tions have  not  been  necessary,  the  time  when 
irregularities  can  be  corrected  with  ease  is  rapidly 
passing  away.  Very  prominent  upper  teeth  should 
be  pushed  back,  narrow  upper  jaws  should  be 
widened,  "under  hung"  jaws  reduced  by  either 
forcing  the  lower  teeth  back,  or  pushing  the  upper 
ones  forward,  which  is  generally  the  easier  way  if 
it  suits  the  face.  These  cases  are  often  spoken  of 
as  family  peculiarities,  and  therefore  not  to  be 
meddled  with ;  but  it  is  difficult  to  see  why  a  de- 
formity that  is  curable,  should  be  perpetuated 
because  it  is  an  heirloom.  It  will  be  useless,  how- 
ever, for  the  dentist  to  urge  the  treatment  if 
parents  do  not  care  about  it.  The  appliances 
necessary  for  operations  of  this  nature  have  to  be 
worn  constantly,  day  and  night,  at  meal  times  and 
play  time.  They  are  sometimes  so  secured  in  the 
mouth  that  they  cannot  be  taken  out  by  the  patient, 
but  usually  they  can  be  removed  for  cleansing  night 


88  DENTAL    PRACTICE. 

and  morning,  and  this  is  all  the  indulgence  that 
can  be  permitted.  They  are  often  so  constructed 
that  bands  or  springs  of  gold  or  platinum  are 
conspicuously  visible  in  the  front  of  the  mouth, 
and  children  wearing  them  have  to  make  up  their 
minds  to  give  up  parties  for  the  time,  or  stand  a 
little  chaffing  from  their  young  friends,  for  they 
cannot  have  the  plates  out  of  their  mouths  for  an 
evening's  amusement.  It  therefore  requires  some 
degree  of  resolution  and  ability  to  deny  one's  self, 
on  the  part  of  the  child,  and  such  encouragement 
on  the  part  of  the  parent  as  can  only  be  given 
when  there  is  an  appreciative  desire  to  assist  the 
dentist  in  every  possible  way.  The  fullest  co-opera- 
tion on  the  part  of  parent  and  child  must  be 
secured,  and  failing  this,  the  most  skilful  dentist 
will  not  accomplish  anything  of  importance  in 
correcting  malposition  of  the  teeth ;  and  the  most 
probable  result  will  be  a  feeling  that  the  one  party 
has  been  unjust,  and  the  other  incompetent.  On 
the  other  hand,  when  everybody  really  wishes  for 
success  in  treating  such  cases,  almost  anything  is 
possible.  The  dentist  is  not  weighted  with  the 
depressing  feeling  that  he  is  the  only  one  interested 
in  the  case,  and  that  the  other  parties  are  only 
obeying  his  instructions  under  protest.  The  child  is 
encouraged  to  persevere  by  the  quick  instinct  which 
tells  when  others  are  sympathetic  or  the  reverse, 
and  the  parent,  interested  in  what  is  shown  to  be 
possible,  gains  confidence  as  the  work  progresses, 
takes  care  that   instructions   are  carried   out,  and 


IRREGULAKITIES.  89 

that  the  work  shall  not  fail  from  negligence.  Clean- 
liness should  be  insisted  upon,  and  in  this  too  the 
parents'  aid  is  needed,  for  some  of  the  retaining 
plates  have  to  be  worn  for  months,  and  if  there  is 
not  scrupulous  cleanliness,  we  may  be  doing  harm 
to  some  of  the  teeth  while  improving  others.  If 
the  plate  is  of  such  a  nature  that  it  can  be  taken 
out  of  the  mouth,  it  should  be  removed  twice  a 
day,  and  those  parts  which  are  covering,  or  in 
contact  with,  the  teeth,  should  be  carefully  cleansed 
with  a  brush.  The  teeth  also  must  be  kept  as  clean 
as  possible,  by  using  a  soft  brush,  or  if  the  teeth 
and  gums  are  too  sore  for  that,  a  small  sponge  fixed 
on  a  handle  should  be  used,  and  every  part  that  can 
be  reached  when  the  plate  is  immovable  should  be 
sponged  with  a  weak  solution  of  carbolic  acid,  or 
phenate  of  soda,  or  sanitas — any  of  which  pre- 
parations can  be  effectively  used  to  keep  down 
inflammation,  and  assist  in  keeping  the  parts  clean, 
and  removing  lodgments  of  food.  If  the  gums  swell, 
as  they  may  do  if  many  teeth  are  being  moved  at 
the  same  time,  the  pressure  should  not  be  increased 
for  a  few  days,  and  astringents  may  be  used  with 
advantage. 

Screws  and  springs,  fixed  in  a  vulcanite  frame, 
as  the  case  may  require,  will  move  any  number  of 
teeth  to  any  necessary  extent,  even  when,  as  the 
following  case  will  show,  the  patient  is  considerably 
beyond  the  age  at  which  these. operations  are  usually 
undertaken.  A  young  lady  had  never  seen  the  left 
upper  canine,  but  a  peculiar  thickness  in  the  palate 


90 


DENTAL    PRACTICE. 


immediately  behind  the  lateral  incisor  indicated  that 
probably  the  tooth  was  there.  When  the  young  lady 
was  three  and  twenty,  the  point  became  visible  far 
inside  the  arch,  and  behind  the  lateral,  which  at 
this  time  had  become  very  prominent.  There  was 
plenty  of  space  for  the  canine  in  its  natural  position, 
and  I  determined  to  try  to  move  it.     Fig.  40  shows 


Figure  40. — Sbowing  a  misplaced  and  very  late  erupting  canine. 

the  position  of  the  tooth  when  I  commenced  the 
operation.  After  several  ineffectual  attempts  to 
apply  the  necessary  amount  of  pressure,  which  was 
difficult  because  the  apparatus  would  slip  off  the 
teeth  now  and  then,  I  finally  hit  upon  the  plan 
shown  in  Fig.  41.  The  frame  of  vulcanite  fitting 
tightly  over  the  back  teeth,  so  that  it  required  con- 
siderable force  to  remove  it,  enabled  the  patient  to 
masticate  her  food  without  permitting  the  lower 
front  teeth  to  come  in  contact  with  the  apparatus  for 


IRREGULARITIES.  91 

moving  the  tooth,  which  consisted  of  a  thick  strong 
spring  of  gold,  fixed  in  the  buccal  surface  of  the  vul- 
canite outside  the  second  bicuspid  and  the  molars, 
with  the  point  resting  on  the  lateral.  '  A  triangular 
boss  was  soldered  on  the  spring  at  a  point  im- 
mediately in  front  of  the  first  bicuspid,  so  as  to 


Figure  41. — Showing  apparatus  for  moving  misplaced  canine. 

make  a  flat  surface  at  a  right  angle  to  the  line  in 
which  I  wanted  the  tooth  to  move,  and  a  hole  was 
drilled  through  this  boss.  A  screw  was  then  cut  on 
a  piece  of  strong  gold  wire,  with  a  pointed  hook  at 
one  end  and  a  nut  at  the  other.  I  then  made 
with  a  drill,  a  shallow  indentation,  in  the  enamel  of 
the  lingual  surface  of  the  tooth,  for  the  point  of  the 
hook  to  rest  in.  The  screw  end  of  the  hook  was 
then  passed  through  the  hole  in  the  boss,  and  the 
nut  turned  up,  and  a  key  fitting  the  nut  given  to 
the  patient  with  instructions  to  screw  it  up  twice 
in  every  twenty-four  hours  if  the  tooth  did  not  get 
too  sore,  and  to  let  me  see  it  once  a  week,  to  remove 


92 


DENTAL    PEACTICE. 


and  cleanse  the  plate,  and  to  see  if  all  was  going 
on  well.  It  will  be  seen  at  once  that  such  an 
apparatus  would  move  any  tooth  to  any  distance, 
the  only  difficulty  was  to  make  the  plate  itself 
so  fast  that  it  could  not  be  disturbed  by  the 
turning  up  of  the  screw,  or  by  mastication.  The 
tooth  was  moved  to  its  proper  position  in  six  weeks 
without  any  inflammation,  and  the  lateral  also  was 
pressed  back  to  its  place.  The  canine  was  easily 
kept  in  its  position  by  the  occlusion  of  the  jaws, 
when  it  was  once  outside  the  lower  teeth  it  could 
not  get  back;  but  the  lateral  required  a  retaining 
plate  for  some  weeks,  and  even  then  it  was  left 
off  too  soon,  as  the  model  of  the  mouth  at  the 
present  time  will  show,  Fig.  42.     The  age  of  the 


y^ 


Figure  42. — Sbowing  position  of  teeth  from  a  model  taken  three  years  later. 


patient,  and  the  distance  the  tooth  had  to  be  moved, 
made  this  rather  a  doubtful  case  at  first,  as  most 
young  ladies  of  that  age  would  not  care  to  have 


IRREGULARITIES. 


93 


such  a  clumsy  apparatus  in  the  mouth  for  several 
months;  but  being  convinced  of  the  advantage  to 
herself,  if  it  succeeded,  she  followed  my  instruc- 
tions implicitly.  The  result  was  a  perfect  success, 
for  although  it  is  three  years  since  the  operation 
took  place  and  the  tooth  is  not  even  yet  quite 
down  to  its  full  length,  it  is  steadily  advancing, 
and  although  the  lateral  is  still  a  little  prominent,  it 
has  not  got  worse  in  the  last  two  years,  and  is  not 
likely  to  change  now. 

Fig.  43  shows  a  case  where  the  canine  on  the 


Figure  43. — Misplaced  right  canine  and  left  first  bicuspid. 

right  side  was  very  prominent,  and  the  first  bicuspid 
on  the  left  side  w^as  also  very  prominent — the  lin- 
gual cusp  shutting  outside  the  lower  tooth.  Fig.  44 
shows  the  arrangement  of  springs  for  moving 
these  teeth  into  their  proper  positions — the  springs 
from  the  palatine  surface  pressing  the  bicuspids 
back   into  the  space  made  by  extracting  the  first 


94 


DENTAL    PRACTICE. 


molars,  and  the  buccal  springs  pressing  the  promi- 
nent teeth  into  the  desired  position. 

We  frequently  find  that  cases  of  projecting  upper 
teeth  are  complicated  with  extreme  shortness  of  the 
back  teeth,  which   allows   the   lower  incisors   and 


Figure  44. — Plate  for  regulating  teeth  in  Figure  43,  as  above. 

canines  to  shut  quite  past  their  proper  antagonists 
of  the  upper  jaw  on  to,  and  often  making  deep 
indentations  into   the  fleshy  covering  of  the  hard 


Figure  45. —  Showing  the  upper  front  teeth  projecting,  and  lower  incisors 
and  canines  biting  into  the  hard  palate. 

palate.     Fig.  45.     To  move  the  upper  teeth  back  in 
these  cases,   without   also  correcting   this  form  of 


IREEGULARITIES.  95 

occlusion,  would  be  manifestly  fruitless  labour  and 
trouble ;  because,  when  moved  back,  the  upper  front 
teeth  would  receive  the  bite  of  the  lower  ones  upon 
the  incline  of  the  lingual  surface  before  the  back 
teeth  were  in  contact,  and  it  would  not  take  long  for 
the  powerful  muscles  which  close  the  jaws  to  undo 
such  a  piece  of  work.  Therefore,  the  first  step  in 
treating  a  case  of  this  nature  is  to  induce  the 
molars  and  bicuspids  to  elongate  sufficiently  to  pre- 
vent the  possibility  of  the  lower  front  teeth  ever 
again  touching  the  palate.  Seeing  that  the  back 
teeth  would  always  elongate  when  they  did  not  meet 
an  antagonist  of  the  opposite  jaw,  it  occurred  to  me 
that,  if  a  plate  were  so  constructed  that  the  whole 
biting  force  of  the  jaws  came  upon  the  front  teeth, 
the   back   ones   would   increase   in   length   to   any 


Figure  46. — Showing  form  of   plate    to    take  pressure  off  the  back  teeth, 
so  as  to  allow  them  to  elongate. 

required  extent.  A  vulcanite  plate  was  easily  made 
of  the  required  thickness  at  the  point  of  contact  of 
the  lower  teeth,  and,  fitting  the  palate  well,  it  could 


96  DENTAL   PRACTICE. 

be  kept  in  its  place  by  suction.  Fig.  46.  This  I 
have  found  to  be  perfectly  successful  in  a  number 
of  cases  that  I  have  treated.  Three  months  will  be 
about  the  time  required  to  lengthen  out  the  molars 
and  bicuspids  so  that  the  lower  incisors  would  not 
reach  nearer  than  a  tenth,  or  an  eighth,  of  an  inch 
from  the  palate. 

Fig.    47   gives   a   representation   of  a  very  in- 


Figure  47. — Projecting  upper  teeth,  models  taken  after  the  upper  six  years 
molars  had  been  extracted. 

teresting  case  of  projecting  front  teeth,  the  young 
lady  being  about  fifteen  years  of  age  when  she  was 
first  brought  to  me  for  consultation.  The  upper 
front  teeth  projected  over,  and  when  the  mouth  was 
closed,  were  always  lying  upon  the  lower  lip.  There 
were  wide  spaces  between  the  teeth,  and  the  utter- 
ance of  many  sounds  was  quite  indistinct — indeed  it 
was  on  account  of  this  indistinct  utterance  that  she 
came  to  consult  me.  The  lower  front  teeth  made 
deep  indentations  in  the  mucus  membrane  covering 
the  hard  palate,  nearly  a  quarter  of  an  inch 
behind  the  central  upper  incisors.  The  age  of 
the  patient  making  it  extremely  probable  that  the 


IRREGULARITIES. 


97 


difficulty  was  increasing,  from  the  development  of 
the  wisdom  teeth  causing  an  increase  of  length  in 
the  upper  jaw,  I  determined  to  extract,  at  once,  the 
upper  six-year  molars.  I  then  made  a  plate 
such  as  I  have  just  described,  except  that  having 
the  spaces  where  the  molars  were  extracted,  I 
could  clasp  the  plate  to  the  second  bicuspids,  and 
thus  leave  the  molars  quite  free.     Fig.  48.     It  will 


Figure  48.— Showing  the  position  of  the  bicuspids  three  months  after  the 
extraction  of  the  molars. 

be  seen  that  the  lower  molars  were  not  extracted 
in  this  case,  as  it  was  desirable  to  encourage 
the  development  of  the  lower  jaw  as  much  as 
possible,  and  I  intended  to  force  the  upper  bi- 
cuspids back  into  the  gaps  left  by  the  extraction 
of  the  upper  molars.  In  three  months  all  the  back 
teeth  had  elongated,  so  that  the  molars  and  bicus- 
pids   would    meet    when    the    plate    was    in    the 

G 


98  •  DENTAL    PEACTICE. 

mouth  and  the  jaws  closed,  leaving,  when  the 
plate  was  taken  out,  a  clear  tenth  of  an  inch 
between  the  ends  of  the  lower  incisors  and  the 
palate,  which  was  in  itself  a  great  gain,  as  it  gave 
the  tongue  more  room,  and  helped  the  power  of 
articulation.  The  next  step  was  to  move  the  bicus- 
pids back,  which  was  done  by  making  a  vulcanite 
plate  to  cover  the  upper  molars,  in  order  to  take 
the  bite  of  the  lower  teeth  on  the  molars  and  the 
incisors,  leaving  the  bicuspids  so  that  the  lower 
teeth  could  not  touch  them.  A  fixed  nut  was 
placed  in  the  substance  of  the  vulcanite  opposite 
the  buccal  surface  of  the  molar  on  each  side.  Then 
a  narrow  strip  of  very  thin  gold,  shaped  like  a 
figure  eight,  was  made  to  fit  tightly  over  the  bi- 
cuspids on  each  side,  and  a  piece,  shaped  like  a 
letter  T,  was  soldered  to  the  band,  so  that  it  would 
slip  between  the  two  teeth  and  the 
f  ^>C\  cross  lie  in  the  sulci,  to  prevent 
.  YC^^'^^TbS^  ^^^  band  slipping  too  high  up  un- 
_    „,     .        der  the  o-um.     A   small   ring;,    or 

Figure  49. — Snowing  °  ^  _         " 

the   form  of  band     rather  a  stud  with  a  hole  in  it,  cor- 
and  screw  used  in     responding  to  the  sizo  of  the  screw 

moving    the     bicus-  -■-  ^ 

pids.  The  nut  was  holo  in  the  fixod  uut,  was  also 
pSe.'"*'''™'''"'*'  soldered  to  the  band  opposite  the 
buccal  surface  of  the  second  bicus- 
pid. The  apparatus  was  then  placed  in  position, 
and  a  long  screw,  with  a  square  head,  was  passed 
through  the  stud  into  the  fixed  nut,  and  screwed 
up.  A  key  fitting  the  head  of  the  screw  was  then 
given  to  the  father  of  the  young  lady,  with  instruc- 


IRREGULARITIES. 


99 


tions  to  turn  the  screw  ever}^  day  as  much  as  she 
could  bear,  and  to  see  that  the  gums  and  teeth  were 
sponged  twice  a  day  with  a  weak  solution  of  carbolic 
acid,  letting  me  see  the  case  once  a  week,  to  take 
the  plate  off  and  clean  it  thoroughly.  This  treat- 
ment soon  moved  the  bicuspids  back.  Then  another 
plate,  with  a  clasp  fitted  around  the  mesial  surface 


Figure  50. — Showiug  the  position  of  tlie  bicuspids  aftcv  moving  them. 


Figure  51. — Side  view  of  the  upper  teetii  at  this  stage. 

of  the  first  bicuspid,  held  them  there,  until  the  new 
alveoli  were  properly  formed  around  them,  as  I 
thought  it  best  to  let  these  teeth  get  well  established 
before  I  moved  the  others.     Figs.  50  and  51.     The 


100 


DENTAL    PEACTICE. 


plate  for  moving  the  front  teeth  was  fitted  over  the 
molars  and  bicuspids.  The  fixed  nut  was  placed 
opposite  the  first  bicuspid,  and,  of  course,  the  plate 
had  to  be  kept  well  back  in  the  palate,  allowing 
fully  half  an  inch  between  its  anterior  edge  and  the 
lingual  necks  of  the  front  teeth.  A  long  strip  of 
thin   gold  was  cut   in   the   shape   of  Fig.  52,  the 


Figure  52. — Showing  the  form  of  the  strip  of  gold  that  was  used  for 
moving  the  front  teeth. 

lips  being  intended  to  be  bent  over  the  cutting 
edge  of  the  central  incisors  to  keep  the  band 
from  slipping  up  on  to  the  gum,  and  studs  were 
soldered  to  the  ends  for  the  screws  to  pass 
through.  The  canines  being  always  rather  difficult 
teeth  to  move,  I  made  a  separate 
loop  for  each  of  them,  thus — 
Fig.  53  —  having  holes  through 
the  ends,  which  were  bent  so  that 
the  holes  would  come  opposite 
the  holes  in  the  studs  at  the  ends 
of  the  long  strip  that  went  round  the  front  teeth, 
allowing  the  screw  to  pass  through  both  ends  of  the 
loop,  as  well  as  through  the  stud.  Fig.  54.  This 
soon  forced  all  the  teeth  back  to  the  required 
position.  Another  plate,  with  a  plain  band  fixed  in 
the  vulcanite,  passing  around  the  front  or  labial 
surface  of  all  the  teeth,  with  hooks,  as  before,  bent 
over  the  cutting  edge  of  the  central  incisors,  to  keep 


Figure  53. — Showingthe 

form   of   loop  used  for 

the  canines. 


IRREGULARITIES. 


101 


it  from  slipping,  kept  all  these  teeth  in  position 
until  the  alveoli  were  properly  formed  and  the  teeth 
quite  firm  in  their  new  position.     The  process  of 


Figure  54. — Showing  the  regulating  apparatus  in  position,  with  the  loops  for 
canines  omitted. 

moving  all  these  teeth  to  the  extent  necessary 
caused  a  great  deal  of  imflammation  and  swelling  of 
the  gums  on  the  lingual  side.  Fig.  55  is  from  a 
model,  taken  when  first  the  teeth  were  in  a  satisfac- 
tory position.  Great  care  was  taken  to  syringe  the 
gums  well,  in  order  to  remove  all  lodgments  from 
around  the  necks  of  the  teeth,  and  they  were  also 
constantly  sponged  with  the  carbolic  lotion,  so  that 
the  swelling  soon  went  down  without  any  disagree- 
able results.  I  saw  the  young  lady  about  six 
months  after  she  had  left  off  the  retaining  plate, 
and  the  teeth  were  quite  firm  in  their  sockets,  and 
there  was  no  appearance  of  the  old  unnatural  pro- 
jection.    This  was  an  operation   that  would   have 


102 


DENTAL    PRACTICE. 


been  impossible  without  the  aid  of  home  influence 
and  assistance,  and  the  work,  extending  over  a 
period  of  eighteen  months,  was  a  pretty  severe  trial 


fA,  €^_  J^  ^ 


Figure  55. — Showing  the  condition  of  the  gums  immediately  after  the  teeth 
had  been  moved  into  the  desired  position. 

of  patience  for  a  young  girl ;  but  she  bore  it  ex- 
tremely well,  and  assisted  me  in  every  way  that  she 
could. 

Another  case   of   projecting    upper    teeth   was 


Figure  56. — Another  case  of  projecting  upper  teeth. 

much  more  easily  treated,  because  the  back  teeth 
were   of  natural  length.     Fig.    56    will    show    the 


IRREGULARITIES. 


103 


condition  of  this  month  when  I  first  saw  it,  the 
young  lady  being  then  about  thirteen  years  of  age. 
Some  one — I  never  ask  who  does  these  senseless 
things — had  extracted  two  lower  bicuspids ;  but 
why  this  had  been  done  it  would  be  impossible  to 
say,  unless  it  w^as  felt  that  something  must  be  done 
to  make  a  charge  for,  as  any  man,  who  thought  at 
all  of  what  would  be  best  for  the  patient,  would  have 
seen  that  the  lower  jaw  was  already  too  small,  and 
therefore  that  its  growth  should  be  encouraged  by 
all  possible  means,  and  not  stopped  by  extractions  on 
each  side.  As  it  was,  the  best  thing  to  be  done  was 
to  extract  the  first  upper  bicuspids  and  move  the 
canines  and  incisors  back.     I  commenced  with  the 


Fifoire  57. — Showing  the  form  of  loop  used  in  moving  the  canines.     The 

straight  bar  projecting  from  the  buccal  surface  of   the  plate  is  intended 

to  prevent  any  outward  movement  of  the  teeth. 


canines,  to  avoid  the  excessive  amount  of  inflam- 
mation that  so  often  results  from  moving  a  number 
of  teeth  at  the  same  time.  A  frame  was  made  of 
vulcanite,  covering  the  two  molars  and  the  second 


104 


DENTAL    PRACTICE. 


bicuspid  on  eitiier  side  with  a  fixed  nut  opposite 
the  bicuspid.  Then  a  loop  of  thin  gold  plate,  like 
that  shown  in  Fig.  57,  was  fitted  to  each  canine,  and 
a  square-headed  screw  and  key,  as  before,  quickly 
accomplished  the  removal.  But  they  were  also 
drawn  rather  out  of  the  arch  and  elongated,  pro- 
bably from  being  moved  so  rapidly  into  the  spaces 
where  bicuspids  had  been  recently  extracted.  To 
correct    this  I   made  another   plate,  Fig.  58,"  with 


Figure  58. — Form  of  plate  for  moving  canines  inwar J,  and  at  the  same  time 
shortening  them  ;  showing  lingual  surface. 

a  strong  clasp  passing  round  the  labial  and  mesial 
surfaces  of  the  canines,  and  a  strip  of  stiff  gold  plate 
springing  from  the  palate,  with  the  free  end  resting 
on  the  points  of  the  teeth,  thus  making  an  incline 
which,  as  the  teeth  were  pressed  inwards  by  the 
clasps,  must  shorten  them  by  forcing  them  into  the 
sockets.  I  then  cut  away  the  vulcanite  from 
around  the  necks  of  the  canines  to  allow  them  to 
move  into  their  proper  place  in  the  arch,  and 
bending  the  clasps  so  as  to  press  on  the  labial 
surfaces  of  the  teeth,  they  were  very  quickly  in  the 


IRREGULARITIES. 


105 


position  I  wished  them  to  be,  aud  of  the  right 
length.  This  plate  was  worn  until  the  canines  were 
firmly  fixed  in  their  sockets,  and  then  I  moved  the 
incisors  back  with  springs  of  stiff  gold  wire,  fixed  in 
the  buccal  surface  of  another  plate  shown  in 
Fig.   59.      All   this  was  done  without  any  serious 


Figure   59. — Form  of    plate  for    moving  all    the  upper  incisors  inward ; 
showing  lingual  surface. 


Figure  60. — Retaining  plate  in  position. 

inflammation.     When  the  teeth  were  as  far  back  as 
I  wanted  them,  the  plate,  Fig.  60,  held  them  all  in 


106  DENTAL    PRACTICE. 

position  for  six  months,  when  the  casts  shown  in 
Fig.  61  were  taken. 


Figure  61. — Showing  articulation  of  teeth  at  this  stage. 

Another  member  of  the  same  family,  a  younger 
sister  of  ten  years  of  age,  also  had  projecting  front 
teeth,  with  the  compHcation  shown  in  Fig.  45, 
the  lower  incisors  shutting  deeply  into  the  palate, 
and  the  projection  quite  as  conspicious  as  in  that 
case  ;  hut  she  was  late  in  getting  her  second  teeth, 
and  the  canines  and  second  bicuspids  were  not 
erupted.  I  pressed  the  incisors  back  with  springs, 
as  in  the  last  case,  and,  in  making  a  plate  to  retain 
them  in  position,  the  same  plan  was  adopted  that  I 
made  use  of  in  that  case,  strips  of  thick  gold  plate 
from  the  palate  being  bent  over  the  cutting  edge  of 
the  front  teeth.  But  in  this  case  I  also  made  the 
plate  of  sufficient  thickness,  where  it  would  receive 
the  bite  of  the  lower  incisors,  to  give  the  back  teeth 
a  chance  of  elongating  as  much  as  was  necessary  to 
keep  the  lower  front  teeth  from  touching  the  palate  ; 
thus  inverting  the  process  adopted  in  a  former 
case,  where  the  lengthening  of  the  back  teeth 
was  the  first  step  in  the  treatment.  But  this 
patient   was   so    much  younger,   that   I    thought  I 


IRREGULARITIES.  107 

might  venture  to  simplify  the  process.  The  result 
justified  my  treatment,  for  there  was  no  swelling  of 
the  gums  to  prevent  her  wearing  a  plate  of  this 
construction  after  the  moving  of  the  front  teeth  was 
accomplished,  whereas  in  the  former  case,  with  the 
gums  swollen,  as  shown  in  Fig.  55,  this  would  have 
been  impossible. 

The  upper  jaw  may  be  too  narrow,  and  from 
this  cause  alone  the  front  teeth  may  be  forced  too 
far  forward.  A  case  of  this  nature  is  shown  in 
Fig.  62.      The  outer  instead  of  the  inner  cusp  of 


Figure  62. — Showing  faulty  articulation  of  all  the  teeth. 

the  upper  bicuspids  is  in  the  sulci  of  the  lower 
teeth,  thus  making  the  upper  jaw  too  narrow  by 
exactly  the  largest  diameter  of  the  crown  of  a 
bicuspid,  or  rather  more  than  a  quarter  of  an  inch. 
The  obvious  treatment  here  is  to  press  the  bicuspids 
and  canines  out,  in  order  to  give  the  jaw  the  proper 
width,  and  thus  gain  room  to  press  the  incisors 
inwards  ;  thus  very  considerably  altering  the  form 
of  the  upper  jaw,  as  shown  by  comparison  of  Fig. 


108 


DENTAL    PRACTICE. 


63  with  Fig.  64.      Fig.  65  shows  the  articulation 
after  treatment.     This  was  done  twenty  years  ago, 


Figure  63. — Showing  the  form  of  upper  jaw  before  treatment. 


Figure  64. — Showing  the  form  of  upper  jaw  after  treatment. 

with  a  vulcanite  plate  and  wooden  wedges  ;  but  a 
much  more  simple  and  expeditious  method  would  be 
one  I  have  adopted  in  a  somewhat  similar  case 
recently  under  treatment.     A  stiff  bar  of  gold,  or 


IRREGULARITIES. 


109 


platinum,  is  made  to  fit  the  necks  of  the  bicuspids 
and  canines  on  either  side.     One  side  is  made  with 


Figure  65. — Showing  the  articulation  after  treatment. 

a  wedge-shaped  projection,  or  boss, — 
which  should  be  notched  in  the 
middle,  —  opposite  the  first  bicuspid, 
and  the  other  with  a  cup -shaped  pro- 
jection in  the  corresponding  position. 
(Fig  66.)     These  may  be  tied  to  the 

Figure  66.— Show-     ^      ^  ^  .        . 

ing  form  of  braces   teeth  to   prevent    slippmg,   and  then 
to   be    used   in   ^^^  ^f  g^  g_  White's  jack-screws,  with 

widening   the  up-  *' 

per  jaw  in  concec-   ouc   end   forked   and   the   other   end 
tionwith  the  jack       i^^^-g^   ^^^  ^^  ^^^  ^^j.]^  ^^  ^  quarter 

screw.  J-  '  -•■ 

of  the  time  it  took  with  the  wedges. 
Then  the  plate  which  would  be  necessary  to  keep  the 
width  that  was  gained,  could  be  utilized  to  press 
the  incisors  into  their  proper  place  in  the  arch,  by 
using  springs  from  the  buccal  surface  on  each  side. 

It  might  be  said  that  no  child  would  tolerate  a 
jack-screw  used  in  this  way  across  the  palatine  arch; 
but  I  have  not  found  any  difficulty  of  this  nature. 
On  the  contrary,  I  have  used  them  repeatedly,  and 
trusted  the  children,  or  their  parents,  to  screw  them 
up,  and,  as  a  rule,  they  are  more  apt  to  do  too  much 


110  DENTAL    PRACTICE. 

of  it  than  too  little.  In  one  case,  a  boy  of  fifteen 
used  one  of  these  screws  in  his  own  mouth  so 
severely,  in  widening  the  jaw  between  the  bicuspids, 
that  he  opened  a  space  of  nearly  a  sixteenth  of  an 
inch  between  the  central  incisors,  where  there  was 
no  space  when  the  screw  was  put  in.  Apparently  he 
had  actually  opened  the  suture  in  the  maxillary  bone. 
But  another  method  of  using  screws  for  widening 
the  upper  jaw  is  quite  as  effective,  yet  by  being 
attached  to  a  plate  fitting  the  palate,  the  apparatus 


Figure  67.  — Showing  another  form  of  screw  to  be  used  in  widening  the 
upper  arch,  with  the  lever  for  turning  the  screw. 

is  not  so  liable  to  be  displaced  by  the  tongue.  The 
plate  fits  the  palate  and  the  lingual  surfaces  of  all 
the  teeth,  except  those  that  are  to  be  moved,  and 
they  are  fitted  with  the  shaped  bars  and  bosses, 
shown  in  Fig.  66.  A  fixed  nut  is  secured  in  the 
vulcanite  opposite  the  palatine  surface  of  the  teeth 
to  be  removed,  and  a  screw  with  a  conical  head,  as 
in  Fig.  67,  will  be  found  effective.  There  must  be 
holes  through  the  head  of  the  screw  for  turning  it. 

In  all  these  cases  much  more  time  is  required  to 
allow  the  alveolus  to  close  firmly  around  the  tooth 
in  its  new  position  than  is  necessary  to  move  the 


IRBEGULARITIES.  Ill 

tooth ;  but  it  is  essential  that  this  time  should  be 
given  and  the  tooth  held  securely  until  the  new 
bone  is  formed.  If  one  or  two  teeth  are  to  be 
moved  forward,  and  we  move  them  far  enough  to 
make  it  certain  that,  when  the  jaws  are  closed,  the 
lower  teeth  will  go  well  inside  the  upper,  and  over- 
lap far  enough  to  keep  them  there,  we  need  not  take 
any  further  precaution.  Or  in  moving  a  bicuspid, 
if  the  cusps  articulate  properly,  and  the  soreness 
is  not  such  as  to  make  the  patient  shrink  from 
closing  the  teeth,  they  will  be  safe,  but  if  the  closing 
of  the  teeth  does  not  make  it  an  impossibility  for  it 
to  do  so,  a  tooth  that  has  been  moved  will  certainly 
go  back  to  its  original  position,  unless  we  contrive 
some  efficient  means  to  retain  it  in  its  new  position 
for  three  months  at  least,  or  until  the  new  alveolus 
is  properly  formed. 

Other  cases,  and  the  appliances  used  in  treating 
them,  might  be  described,  but  enough  has  been 
written  to  show  the  usefulness  of  screws  and  springs 
in  these  operations,  and  to  give  a  general  idea  how 
they  may  be  applied  ;  but  every  individual  case  will 
require  some  modification  of  the  treatment,  and  this 
must  be  wrought  out  by  the  dentist  who  undertakes 
the  case,  and  whose  inventive  powers  should  enable 
him  to  do  this,  if  he  is  ever  to  take  any  position  in 
his  profession. 

I  have  inserted  here  drawings  (Figs.  68  to  72) 
of  a  few  forms  of  plates  that  have  been  used  in 
practical  cases  of  regulating,  which  may  be  useful 
as  a  suggestion  for  young  practitioners. 


112 


DENTAL    PRACTICE. 


Figure  68. — Form  oi'  I'liito  ;or  innving  a  central  incisor  forward;  showing 
palatine  surface. 


Figure  69. — Form  of  plate  for  turning  right  central  in  its  socket,  when  it 

has  a  tendency  to  overlap  the  left  central.     The  spring  on  the  left  side  is 

intended  to  prevent  any  movement  of  the  left  central.     Palatine  surface. 


Figure  70. — A  form  of  retaining  plate  ;  showing  palatine  surface 


IRREGULARITIES. 


113 


Figure  71. — Form  of  plate  for  moving  a  lateral  incisor  forward  ;   showing 
lingual  surface. 


Figure   72.— Plate  for  regulating  overlapping  central  incisors.      Lingual 

surface. 


114 


CHAPTEE  V. 


Treatment  of  Adult  Teeth. 

My  theme  so  far  has  been  the  care  and  treat- 
ment of  the  teeth  in  childhood  and  youth ;  but 
there  comes  a  time  when  we  must  begin  to  treat 
them  as  adult  teeth,  and  it  is  an  important  ques- 
tion when  this  change  of  treatment  shall  commence. 
We  cannot  lay  down  fixed  rules  for  our  guidance 
in  this  any  more  than  in  numerous  other  ques- 
tions that  come  up  for  consideration  every  day  in 
dental  practice.  It  is  best,  as  I  have  said  before, 
not  to  begin  until  a  certain  number  of  birthdays 
have  passed ;  yet  it  is  by  no  means  a  safe  criterion 
for  a  change  of  practice  that  a  patient  has  attained 
the  age  of  sixteen.  The  condition  of  the  mouth 
must  indicate  when  it  is  time  to  begin  what  may 
be  called  permanent  work.  If,  when  the  patient 
is  sixteen,  the  teeth  are  still  decaying;  still  very 
sensitive ;  the  secretions  still  of  the  viscous  ropy 
character  indicative  of  acidity;  or  if  the  patient 
has  been  growing  so  fast  as  to  outrun  the  strength  ; 
or  if  pride  of  appearance  has  not  yet  created  a 
feeling  of  interest  in  the  preservation  of  the  teeth, 
we  had  better  trust  to  our  plastic  work  a  little 
longer   and  renew  it   as   occasion   requires.      But 


TREATMENT  OF  ADULT  TEETH.        115 

when  a  year  has  passed  without  a  new  cavity 
appearing  in  any  tooth ;  when  the  gums  look  firm 
and  healthy,  and  have  lost  the  slippery  feeling  that 
is  produced  by  viscid  secretions ;  when  we  can 
remove  one  of  the  gutta-percha  fittings  and  prepare 
the  cavity  for  gold,  without  giving  any  acute  pain  ; 
when  health  and  strength  are  keeping  pace  with 
growth ;  and  when  evidences  of  attention  to  cleanli- 
ness manifest  themselves,  we  may  begin  to  treat  the 
mouth  with  permanent  fillings,  and  have  a  reason- 
able hope  that  our  work  may  deserve  that  description. 
A  tooth  that  is  very  sensitive,  really  so,  is  not  fit 
to  be  treated  with  a  metallic  stopping  of  any  kind. 
When  I  say  really  sensitive,  I  mean  when  the 
dentist  is  himself  convinced  of  the  supersensitive 
condition  of  the  dentine,  for  we  constantly  have 
patients  who  cry  out  that  we  are  torturing  them, 
when  the  imagination  has  more  to  do  with  the 
suffering  than  the  operator  has,  and  in  such  cases 
"we  must  use  our  own  judgment.  It  is  certain,  how- 
ever, that,  in  cases  where  there  is  truly  excessive 
sensibility,  the  decay  will  go  on  in  spite  of  the 
filling,  if  it  is  of  metal.  This  is,  without  doubt, 
partly  owing  to  the  inability  of  the  operator  to  make 
sufficiently  perfect  work  when  the  patient  is  fidgeting 
under  the  pain  he  is  inflicting ;  but  I  am  inclined 
to  think  it  is  also  partly  due  to  a  degree  of  inflam- 
mation of  the  dental  fibrils,  which  is  a  preliminary 
stage  of  decay,  and  which  the  quick  conducting 
nature  of  a  metal  filling,  in  absolute  contact  with 
them,  excites  and  maintains,  possibly  until  a  vitiated 


116  DENTAL    PEACTICE. 

exudation  from  them  becomes  a  destructive  agent, 
when  the  dentine  breaks  down  and  is  destroyed 
under  the  fiUing,  as  we  know  that  the  alveolus, 
and  the  cementum  and  dentine  itself,  are  sometimes 
destroyed  by  the  unhealthy  exudation  in  alveolar 
abscess.  In  excavating  a  cavity  in  a  tooth  we 
generally  find  that  the  most  sensitive  parts  are  the 
extreme  edges,  where  it  is  reasonable  to  suppose 
that  the  decay  is  most  actively  proceeding ;  and  how 
often  we  have  to  lament  the  failure,  at  these  points, 
of  work  that  seemed  to  us  to  come  very  near  perfec- 
tion. The  floor  of  the  cavity  is  rarely  its  most 
sensitive  point,  unless  the  nerve  is  really  exposed, 
which  is  a  different  matter,  and  fillings  do  not,  as  a 
rule,  fail  at  this  point.  The  change  of  position  of 
two  teeth,  that  are  filled  on  the  approximal  surfaces, 
so  as  to  bring  the  edges  of  the  fillings  in  contact, 
and  the  consequent  lodgment  of  food  and  secretions 
there,  when  the  dentist  has  designed  them  to  be 
kept  apart,  and  to  be  self-cleansing,  do  not  always 
satisfactorily  account  for  these  failures.  A  con- 
tinuance of  the  inflammation,  which  made  that 
particular  point  so  sensitive  while  we  were  operat- 
ing, and  a  breaking  down  of  the  dentine  there  would 
account  for  failures  which  we  cannot,  in  justice  to 
ourselves,  admit  to  have  been  owing  to  unskilful 
work.  But,  if  the  filling  is  of  a  non-conducting 
nature,  the  inflammation  is  soothed  and  allayed, 
recalcification  becomes  possible  and  probable,  and 
after  a  time  a  metal  fitting  is  tolerated,  and  will  be 
an  effectual  preservative. 


TREATMENT  OF  ADULT  TEETH.        117 

It  is,  therefore,  not  only  a  comfort  to  the  patient 
to  be  saved  the  pain  of  having  a  gold  Ming  inserted 
at  once  in  a  newly-discovered  and  sensitive  cavity, 
but  it  is  a  positive  advantage  to  have  been  made 
comfortable.  It  is  my  theory,  that  the  com'se  of 
treatment  I  have  sketched  will  bring  the  tooth  to 
that  condition  of  non-progressive  decay  and  absence 
of  inflammation  in  the  cavities  which  Dr.  Foster 
riagg  so  well  describes  as  cases  that  anybody  can 
save  with  gold,  and,  however  skilful  we  may  be,  it 
is  more  satisfactory  to  feel  that  we  have  made  the 
conditions  under  which  our  work  is  done  so  favour- 
able that  success  is  easy,  than  to  feel  that  we  have 
made  a  difficult  and  troublesome  operation,  which 
may  be  a  failure  from  no  fault  of  our  own 

Teeth  which  are  decaying  rapidly  are  always 
supersensitive,  and  it  is  certain,  that  the  best  and 
safest  way  of  reducing  the  sensibility  in  such  cases, 
is  to  protect  the  decaying  surfaces  with  a  non-con- 
ducting substance.  Under  ordinary  circumstances, 
a  few  months  of  such  protection  will  make  it 
possible  to  prepare  the  cavity  for  a  permanent 
filling,  and  then  a  metal  filling  may  be  comfortable, 
while,  if  it  is  inserted  at  once  on  the  sensitive 
surface,  it  is  anything  but  comfortable,  and  I  doubt 
whether  it  will  ever  be  so  effective. 

When  we  are  satisfied  that  the  favourable  change 
we  have  been  waiting  for  in  the  condition  of  the 
mouth  has  really  taken  place,  we  may  begin  to  fill 
the  front  teeth  with  gold,  and  it  should  be  the  aim 
of  every  dentist  to  be  perfect  in  this  department  of 


118  DENTAL   PEACTICE. 

our  art,  which  must  not,  however,  be  regarded  as 
the  whole  or  the  best  part  of  dentistry.  It  is  not 
my  purpose  to  give  any  minute  directions  how  to 
proceed  to  fill  a  tooth  with  gold,  because  written 
instructions,  without  clinical  demonstrations,  would 
never  teach  any  one  this  art.  Every  student  should 
have  the  privilege  of  seeing  skilled  operators  at 
work,  and  of  operating  himself  under  the  eye  of  a 
demonstrator,  whose  judgment  and  ability  no  one 
could  question;  but  a  few  suggestions  will  not  be 
out  of  place. 

A  good  operator  will  keep  the  gold  out  of  sight 
as  much  as  possible,  therefore  the  excavation  for 
fillings  in  approximal  surfaces  of  front  teeth  should 
always  be  made  from  the  lingual  surface,  and  in 
doing  this  the  great  advantage  of  being  able  to  work 
with  the  mirror  is  obvious.  Practice  will  make  it 
easy  for  an  operator  to  do  all  the  work  of  excavating 
and  fiUing  approximal  cavities  in  any  of  the  front 
teeth,  without  looking  once  at  the  work  by  direct 
sight.  Fig.  73  shows  how  to  use  the  mirror  while 
operating  on  front  teeth.  The  familiar  use  of  the 
mirror  will  also  enable  the  operator  to  do  all  his 
work  without  resorting  to  the  cruel,  and,  it  seems 
to  me,  unprofessional  practice  of  wedging  the  teeth 
apart  to  make  room  to  work.  It  is  cruel,  because  it 
adds  greatly  to  the  pain  of  any  operation  on  the 
teeth,  to  have  the  lining  membrane  of  the  socket  in 
a  state  of  inflammation,  from  violence,  at  the  time 
of  operating ;  and  it  is  absurd  to  say  that  the  teeth 
can  be  forcibly  separated,  and  then  left  to  recover 


TREATMENT  OF  ADULT  TEETH. 


119 


from  the  soreness,  before  the  operation  is  pro- 
ceeded with.  When  we  move  a  tooth  in  a  child's 
mouth,  it  is  often  several  months  before  the 
tooth  is  quite  firm  in  its  socket  again;  and  the 
older  the  patient  is,  the  longer  will  be  the  time 
required  for  the  new  formation  of  bone  to  support 
the  tooth   in   its   new  position;    therefore,  if  the 


Figure  73.— Showing  how  the  mirror  is  to  be  held  while  operating  by 
reflection,  the  operator  standing  behind  the  right  shoulder  of  the  patient. 

operation  is  to  be  delayed  until  all  soreness  has  dis- 
appeared, it  would  be  necessary  to  wait  two  or  three 
months  at  least.  But  it  is  probable  that  wedging 
does  not,  at  once,  cause  absorption  of  the  alveolus 
on  the  side  to  which  the  tooth  is  moved,  but  simply 
crushes  it,  as  the  alveolus  is  not  a  very  dense  bone, 


120  DENTAL    PKACTICE. 

and  would  yield,  to  a  certain  extent,  to  pressure. 
This,  however,  does  not  make  it  any  easier  for  the 
patient,  and  does  not  alter  the  fact  that  the  socket 
is  widened,  so  that  pressure  on  the  tooth  is  no 
longer  distributed  over  the  whole  of  the  socket,  but 
is  concentrated  on  the  apex.  If  a  wedge  is  driven 
into  a  piece  of  wood,  nobody  will  deny  that  there  is 
more  pressure  on  the  sides  of  the  wedge  than  on  its 
edge  ;  but  if,  after  the  wedge  has  forced  the  fibres 
of  the  wood  apart,  it  is  removed,  and  a  thinner  one 
put  in  its  place,  the  second  one  will  rest  on  its  edge ; 
and  if  the  socket  of  a  tooth  is  widened  on  one  side, 
the  conditions  are  precisely  similar.  The  tooth  is 
wedge-shaped  to  a  sufficient  extent  to  make  the 
bearing  on  the  walls  of  the  socket  instead  of  on  the 
end,  but  when  the  socket  is  enlarged  the  bearing 
must  be  upon  the  end.  A  tooth  cannot  be  filled 
with  gold  without  a  certain  amount  of  pressure  in 
the  direction  of  the  apex  of  the  root ;  therefore,  if 
the  conical  root  is  not  supported  by  the  walls  of 
the  socket,  this  pressure  must  be  directly  upon  the 
apical  foramen,  and  upon  the  nerve  and  blood 
vessels  of  the  tooth.  Notwithstanding  this,  it  is,  as 
we  all  know,  one  of  the  favourite  methods  of  filling 
teeth  to  wedge  them  apart,  and  then  to  proceed  at 
once,  or  after  a  day  or  two,  to  pack  a  gold  filling, 
condensing  it  with  the  mallet,  and,  of  course, 
leaving  the  patient  to  suppose  that  this  is  the  only 
way  the  work  can  be  done.  It  is  not  surprising 
that  nervous  people  dread  the  dentist's  chair.  I  am 
sure  that  the  vitality  of  many  a  tooth  is  destroyed 


TREATMENT  OF  ADULT  TEETH.         121 

by  this  process,  for  I  have  seen  a  number  of  cases 
where  the  death  of  the  pulp  could  not  be  accounted 
for  by  any  other  hypothesis;  and,  naturally,  the 
great  majority  of  the  cases  of  suffering  from  this 
cause  would  go  back  to  the  operator  who  filled  the 
tooth.  It  is  not  surprising  that  pulps  die,  when 
they  are  crushed  and  bruised,  as  they  must  be,  by 
such  treatment.  The  only  wonder  is  that  any 
remain  alive.  We  know  how  easily  a  pulp  is  de- 
vitalized by  a  blow,  yet  we  first  prepare  it  to  receive 
as  much  harm  as  possible,  and  then  proceed  to  give 
it  a  series  of  hard  knocks. 

Well-shaped  enamel  chisels  are  indispensable, 
even  to  those  who  are  most  fond  of  the  engine  disks, 
for  cutting  away  the  thin,  fragile  enamel,  and  shap- 
ing the  surface  to  be  excavated.  For  front  teeth,  I 
think  this  part  of  the  work  is  much  more  pleasantly, 
and  quite  as  expeditiously,  done  with  the  chisel  than 
with  the  disk.  They  are  made  in  great  variety  by 
all  instrument-makers,  and  they  should  be  thin,  yet 
strong  in  the  blade,  and  tempered  as  hard  as  steel 
can  be  made.  A  few  desirable  shapes  are  shown  in 
Fig.  74. 

Excavators  for  work  with  the  mirror  should  be 
shaped  so  that  the  shank  of  the  instrument  will 
not  come  in  the  reflected  line  of  sight  from  the  edge 
of  the  blade.  This  is  more  important  in  excavators 
for  a  cavity  on  the  left  side  of  a  tooth  than  for  those 
on  the  right  side.  In  the  latter  case,  the  principal 
part  of  the  work  is  best  done  with  an  instrument 
bent  at  a  very  slight  angle,  at  about  a  quarter  to 


122 


DENTAL    PRACTICE. 


three-eighths  of  an  inch  from  the  edge  of  the  blade. 
An  extremely  short  blade,  bent  at  a  right  angle,  is 
also  useful  for  the  lingual  edge  of  the  cavities,  but 
for  cavities  on  the  left  side  of  a  front  tooth  the  in- 
strument should  be  first  a  long  blade,  bent  at  a  right 


r^ 


rfrr 


C] 


rr 


Figure  74. — A  good  practical  set  of  enamel  chisels. 

angle,  for  excavating  the  labial  edge  of  the  cavity, 
and  then  a  variety  of  shapes,  which  I  have  called 
my  swan-neck  instruments  for  want  of  a  better 
name  for  them.  Fig.  75  will  give  an  idea  of  some 
of  the  shapes  for  excavators  and  pluggers.  The 
same  shapes  are  useful  in  packing  the  gold. 


TREATMENT  OF  ADULT  TEETH. 


123 


The  importance  of  acquiring  a  habit  of  resting 
the  fingers,  or  the  thumb,  firmly  on  some  of  the 
other  teeth,  or  on  the  chin,  if  operating  on  the  lower 


r 


Fignrc  75.— A  good  set  of  excavators  for  use  with  the  mirror.     Nearly  all 
these  shapes  are  also  useful  as  pluggers. 

jaw;  or  if  no  other  resting-place  is  available,  on  the 
fingers  of  the  left  hand  (the  left  arm  being  over 
the  patient's  head,  and  the  mirror  held  between  the 


124  DENTAL    PRACTICE. 

second  and  third  fingers),  so  as  to  guard  against 
accidents  from  an  instrument  slipping  or  breaking, 
cannot  be  too  strongly  impressed  upon  the  mind  of 
the  student.  We  often  put  a  very  considerable 
amount  of  pressure  upon  an  instrument,  and  it  may 
be  one  that  we  have  tested  well  in  all  ways,  but  the 
more  it  is  used,  the  more  certain  it  is  to  break  some 
time,  when  we  least  expect  it ;  or  the  point  of 
an  excavator  slips  on  a  surface  of  smooth  enamel, 
and  a  serious  wound  may  result.  When  I  was  a 
student,  my  preceptor  called  me  into  the  surgery 
one  day  to  show  me  a  scar  on  a  lady's  face,  from  a 
wound  made  by  an  instrument  slipping  in  the  hands 
of  a  dentist.  The  lower  lip  had  been  cut  through 
quite  down  to  the  chin,  leaving  an  ugly  cicatrix 
more  than  an  inch  in  length.  I  need  scarcely  say 
that  such  a  lesson  made  a  deeper  impression  on  my 
mind  than  many  lectures  would  have  done.  In  time 
this  resting  of  the  fingers  to  guard  against  a  slip 
becomes  instinctive,  and  is  done  quite  unconsci- 
ously, but  it  must  be  always  in  the  mind  until  the 
fingers  have  learned  to  do  it  of  themselves. 

A  great  deal  has  been  said  about  shaping  the 
cavities  for  approximal  fillings,  but  the  fact  is  that, 
except  in  the  smaller  cavities,  when  but  little  skill 
is  required  to  make  a  safe  filling,  the  extent  and 
position  of  the  decay  have  determined  the  form  that 
the  cavity  must  take,  and  the  dentist  has  only  to 
take  care  not  to  leave  too  many  sharp  angles,  nor  too 
much  overhanging  enamel  on  the  lingual  surface  of 
incisors  and  canines,  when  it  may  easily  be  broken 


TREATMENT  OF  ADULT  TEETH.        125 

down  after  the  filling  is  completed.  It  would  be  as 
absurd  for  a  dentist  to  attempt  to  shape  all  bis 
cavities  alike,  as  it  would  be  for  an  architect  to 
plan  bis  buildings  without  reference  to  the  site  on 
which  they  were  to  be  erected. 

While  it  is  important  to  avoid  weak  edges  of 
enamel  on  the  lingual  surface,  where  all  the  biting 
comes  on  front  teeth,  it  is  equally  important  to  pre- 
serve as  much  as  possible  of  the  labial  enamel, 
even  though  it  may  be  so  thin  that  the  gold  can  be 
plainly  seen  through  its  porcelain-like  transparency. 
Care  and  experience  will  enable  the  operator  to  pack 
gold  against  such  a  wall  by  hand-pressure,  so  as  to 
make  a  good  safe  filling  without  risk  of  breaking ; 
and  there  is  nothing  to  cause  breakage  in  this 
locality  after  filling,  unless  it  is  an  "under-hung" 
jaw ;  and  although  the  gold  may  show  through  the 
enamel,  it  is  not  so  conspicuous  and  ugly  as  when 
it  is  absolutely  uncovered,  and  its  glitter  constantly 
reminding  one  of  the  quartz  and  gold  ornaments  so 
much  w^orn  at  one  time  by  the  Californian  and 
Australian  miners.  There  should  not  be  too  much 
undercutting.  The  slightest  possible  inward  incli- 
nation of  the  lateral  walls  is  amply  sufficient  to 
retain  the  filling,  and  too  much  of  it  increases  the 
difficulty  and  uncertainty  of  the  packing.  The  form 
which  the  cavity  is  to  take  must  be  kept  in  view 
from  the  first.  While  we  are  cutting  down  the 
thin  and  fragile  portions  of  the  enamel,  we  should 
be  noting  the  extent  of  the  decay,  and  planning  our 
work.     The  dentine  decays  more  rapidly  than  the 


126  DENTAL    PRACTICE. 

enamel,  and  there  will  always  be  a  comparatively 
strong  edge  of  enamel  standing  higher  than  the 
sound  dentine  of  the  same  locality,  and  we  should 
preserve  enough  of  this  to  make  the  margin  of  our 
filling  safe  and  strong,  but,  at  the  same  time,  have 
free  access  to  all  parts  of  the  cavity  for  our  instru- 
ments. Therefore,  it  is  best,  after  cutting  away 
what  is  obviously  worthless,  to  put  down  the  chisel 
and  use  the  excavator,  until  we  get  a  good  idea  of 
the  depth  of  the  decay  and  strength  of  the  walls, 
and  then  finish  shaping  the  edges.  All  that  is 
wanted  at  the  lingual  approximal  edge  of  the 
cavity,  is  a  wall  that  can  be  distinctly  felt,  with  a 
good  pointed  excavator,  to  rise  above  the  floor  of 
the  cavity,  and  this  may  be  slightly,  very  slightly, 
undercut.  More  than  this  would  be  in  the  way,  and 
in  every  sense  a  disadvantage,  as  at  this  point  it 
is  best  to  build  up  the  gold  quite  flush  with  the 
lingual  surface  of  the  tooth,  not  to  such  an  extent 
as  to  affect  the  V-shaped  space,  but  enough  to  pro- 
tect the  edge  of  the  enamel  from  fracture. 

When  the  conditions  are  favourable,  it  will  be 
found  that  good  gold  fillings  in  the  teeth  of  young 
people  of  both  sexes,  between  the  ages  of  sixteen 
and  twenty,  will  make  the  teeth  as  good  as  though 
they  had  never  decayed  at  all.  More  than  this  can- 
not, of  course,  be  said ;  for  although  I  contend  that, 
when  a  tooth  needs  filling,  the  filled  surface  should 
be  left  in  the  form  that  will  most  facilitate  cleanli- 
ness, I  do  not  mean  to  say  that  it  is  an  improve- 
ment on  nature,  but  only  that  since  it  has  failed. 


TREATMENT  OF  ADULT  TEETH.        127 

and  needs  to  be  repaired,  the  best  form  that  the 
rejDah*  can  take,  is  that  which  can  be  most  easily 
and  quickly  relieved  from  the  pressure  of  dangerous 
lodgments.  Nothing  can  be  better  than  the  natural 
form  of  the  tooth,  so  long  as  it  has  its  natural 
substance  and  its  impermeable  coating  of  enamel 
intact  to  protect  it;  but  when  this  breaks  down, 
and  we  have  to  restore,  with  a  substance  that  is 
altogether  foreign  and  unnatural,  a  part  which  has 
been  cut  away,  because  it  was  diseased,  we  cannot 
expect  a  perfect  welding  of  the  restoration  upon 
the  natural  structure.  Therefore,  we  help  the 
restoration  by  giving  it  a  somewhat  different  shape. 
Knowing  that  the  joints  are  the  weakest  portions 
of  our  defensive  armour,  we  try  to  make  them  so 
that  the  missiles  of  attack  will  glide  off  without  find- 
ing the  weak  spot.  Thus  it  seems  to  me  that  fillings 
in  front  teeth  and  bicuspids  are  much  safer  when  the 
surfaces  are  left  in  the  forms  shown  in  Figs.  22  and 
25,  than  when  the  contour  is  fully  restored. 

Soft  gold  fillings  are  made  by  using  the  gold 
foil  in  twisted  ropes,  or  in  folded  strips  of  four,  six, 
or  eight  thicknesses — No.  6  being  as  thick  as  the 
foil  can  be  used  with  advantage.  The  folds  are 
slightly  wider  than  the  depth  of  the  cavity,  and 
they  are  packed  by  placing  one  end  of  the  folded 
strip,  or  ribbon  of  foil,  against  the  most  available 
wall  for  commencing  the  work,  and  pressing  it 
down,  then  folding  down  another  layer  and  pressing 
it  down,  then  another  and  another,  pressing  each  a 
little  more  firmly  than  the  fold  before  it,  and  taking 


128  DENTAL    PEACTICE. 

care  to  secure  the  corners  by  wedging  the  gold  well 
into  them,  so  that  the  mass  will  not  '^  rock,"  or  lift 
at  one  corner  when  the  opposite  one  is  pressed 
down.  Strip  after  strip  may  be  packed  into  the 
cavity ;  or  it  may  be  found  best  to  use  the  gold  in 
the  form  of  cylinders,  which  are  made  by  rolling 
strips  of  foil  on  a  watch-maker's  broach,  but  they 
can  be  bought  from  the  dealers  already  prepared  in 
all  sizes  and  lengths  ;  usually  it  will  be  found  that 
it  is  best  to  use  a  combination  of  strips  and 
cylinders,  filling  the  greater  part  of  the  cavity  with 
the  former,  and  finishing  with  the  latter.  A  certain 
amount  of  condensation  has,  of  course,  been  going 
on  all  the  time.  The  corners  have  been  secured, 
and  the  edges  have  been  packed,  but  when  we  have 
packed  in  as  many  pieces  as  there  seems  room  for, 
we  go  over  the  whole  surface  again,  beginning  in 
the  middle  of  the  filling  with  a  small  truncated 
cone-shaped  instrument,  and,  wherever  we  find  a 
soft  place,  we  try,  by  pressing  the  gold  laterally,  to 
force  the  plugger  down  to  the  floor  of  the  cavity, 
and  thus  make  space  for  more  ropes,  or  cylinders. 
Thus  forcing  the  plugger  into  every  soft  spot,  we 
gradually  condense  the  mass,  until  the  plugger  will 
make  no  more  impression  upon  it ;  but  even  now 
the  gold  should  everywhere  stand  higher  than  the 
walls  of  the  cavity.  The  burnisher  may  now  be 
used  over  the  whole  surface  with  plenty  of  muscular 
power,  and  the  surface  filed  down  with  a  thin 
dividing  file  (an  0  0  file  is  not  too  thin  in  the  case 
of  front  teeth).     Then  the  burnisher  must  be  used 


TREATMENT  OP  ADULT  TEETH.         129 

again,  alternately  with  the  file,  until  the  surface  is 
smooth  and  shaped  as  we  wish  it  to  be,  when  the 
polishing  tape  will  complete  the  work.  Very  excel- 
lent fillings  are  made  in  this  way,  and  I  quite 
believe  that  in  many  cases  it  is  the  most  trust- 
worthy method ;  but  we  must  not  be  confined  to 
one  method.  In  general  practice,  one  will,  I  think, 
find  that  lining  the  cavity  with  soft  gold,  packing  it 
well  against  the  lateral  walls  and  floor  of  the  cavity, 
filling  the  cavity  half  full,  in  fact,  and  then  finish- 
ing with  cohesive  gold,  will  give  better  results,  with 
less  time  in  the  manipulation,  especially  in  front 
teeth  which  are  badly  decayed  and  have  thin 
delicate  walls.  A  loose  twist  of  No.  6  foil  is  first 
packed  against  the  cervical  wall  of  the  cavity  and 
part  of  the  labial  wall,  then,  before  it  is  wholly 
condensed,  another  piece  is  packed  into  the  narrow 
part  of  the  cavity  towards  the  cutting  edge,  securing 
these  two  points  so  that  there  is  no  rocking  of  any 
portion  of  the  gold.  Another  piece  may  then  be 
added  at  the  cervical  and  lingual  corner,  and 
secured  there.  Then,  if  the  gold  is  sufiiciently 
clean  and  dry,  that  is,  if  it  has  not  been  fingered 
with  moist  hands,  the  whole  may  be  packed  down 
together, — the  loose  thin  ends  of  the  twists  being  in 
this  way  interlaced.  Only  fine  serrated  points  are 
to  be  used  for  a  filling  of  this  kind,  and  the  surface 
is  never  to  be  smooth  until  the  last  piece  of  gold 
has  been  added.  A  small  piece  of  cohesive  gold 
may  be  added  now  and  then,  while  the  soft  portion 
of  the  filling  is  being  packed  down  and  thoroughly 

I 


130  DENTAL    PEACTICE. 

condensed.  The  cohesive  pieces  serve  to  unite  the 
loose  folds  of  soft  gold,  and,  being  packed  into  the 
corners,  are  useful  for  anchorage  to  the  bulk  of  the 
cohesive  portion  of  the  filling  ;  but  if  sufficient  care 
has  been  taken  to  keep  the  work  and  the  material 
quite  dry,  there  will  be  no  difficulty  about  the  parts 
adhering,  and  the  filling  can  be  built  up  from  the 
soft  gold  foundation,  so  as  to  make  it  a  perfectly 
cohesive  mass.  The  best  soft  gold  can  always  be 
made  sufficiently  cohesive  by  passing  it  through  the 
flame  of  a  spirit  lamp,  thus  thoroughly  drying  away 
the  moisture  it  has  absorbed  from  the  atmosphere,  and 
burning  any  greasy  deposits  it  may  have  received  in 
the  process  of  manufacture,  or  from  subsequent 
handling.  A  filliug  may  be  built  up  to  any  desired 
contour,  if  only  the  ultimate  form  of  the  filling  is 
kept  constantly  in  mind  ;  and  those  parts  which  are 
most  difficult  to  reach  with  the  instruments  are 
built  up  first,  and  so  on,  finishing  with  the  most 
accessible  parts.  Great  care  must  be  taken  to 
finish  the  gold  down  flush  with  the  surface  of  the 
tooth,  particularly  at  the  cervical  edge,  where  any 
projection  of  the  gold,  or  overlapping,  will  quickly 
destroy  the  work  by  causing  renewed  decay. 

Some  practitioners  use  gold  in  the  cohesive 
form  from  the  beginning  of  the  filling.  A  few 
retaining  points  are  made  with  a  drill,  and  then  are 
packed  with  cohesive  gold,  which  is  added  to,  little 
by  little,  until  the  starting  points  are  all  connected, 
and  then  the  work  may  proceed  with  a  little  more 
rapidity.      Screws  are  sometimes   used  instead   of 


TREATMENT  OF  ADULT  TEETH.        131 

retaining  points  made  with  a  drill  simply,  but  as  a 
drill  must  be  used  to  make  the  screw-hole,  and  as 
one  piece  of  gold  can  be  united  to  another  in  a  tube 
so  as  to  sustain  a  weight  almost  equal  to  what 
would  be  sustained  by  the  same  quality  of  gold 
melted  and  drawn  into  wire,  it  is  difficult  to  see 
what  advantage  is  derived  from  the  screw.  It  may 
save  a  little  time  now  and  then  in  very  accessible 
places,  but,  as  a  rule,  the  difficulty  of  securing  the 
screws  only  complicates  the  work  without  any  real 
advantage.  Indeed,  to  any  one  who  has  dry  hands  so 
as  to  be  able  to  make  up  the  twists,  or  folds  of  soft 
foil,  without  making  the  gold  greasy,  there  can  be 
no  possible  advantage  in  making  the  whole  filling  of 
cohesive  gold. 

The  student  should  first  learn  to  do  these  things 
well,  and  then  to  do  them  quickly.  The  amount  of 
time  spent  in  many  operdltions  on  the  teeth,  and 
the  appliances  which  become  necessary,  because  of 
the  time,  render  these  operations  far  more  formid- 
ble  to  the  patient,  and  fatiguing  to  the  operator, 
than  is  necessary  or  profitable.  And  here  let  us 
consider  who  is  benefited  by  the  greater  part  of  the 
modern  appliances  used  in  operations  on  the  teeth. 
Admitting  that  a  man  must  be  paid  for  his  work, 
and  for  the  time  he  has  spent  in  learning  to  do  it, 
the  chief  object  in  the  practice  of  dentistry  is,  or 
should  be,  the  good  of  the  patient.  The  ideal 
physician  is  not  one  who  makes  it  the  chief  object 
of  his  life  to  put  money  in  his  purse ;  and  even 
looking  at  it  from  the  purely  selfish  point  of  view. 


132  DENTAL    PRACTICE. 

lie  would  not  find  it  for  his  interest  to  have  his 
patients  consider  this  to  be  the  ruling  motive  of  his 
practice.  Nor  would  any  one  be  willing  to  admit 
that,  in  our  own  speciality,  the  chief  end  of  dental 
practice  is  the  glory  or  profit  of  the  dentist.  What, 
then,  is  the  object  of  the  greatly  increased  amount 
of  labour  and  time  bestowed  upon  these  operations 
now,  compared  to  those  of  thirty  years  ago  ?  The 
best  operators  of  those  days  saved  the  teeth,  and 
made  them  useful.  Many  of  their  fillings  are  to  be 
found  in  the  teeth  of  middle-aged  men  and  women 
now,  yet  I  doubt  if  many  of  them  spent  four  or  six 
hours  over  any  one  fiUing.  Someone  will  say  that 
they  condemned  many  teeth  which  are  now  saved. 
It  may  be  so,  but  the  teeth  that  they  considered 
hopeless,  can  be  saved,  and  made  comfortable  with- 
out spending  so  many  hours  over  them,  as  I  will 
show  later  on.  But  do  we  now,  by  spending  so 
much  more  time  and  labour,  save  the  majority  of 
the  teeth  we  fill  any  longer  than  they  did  by  their 
much  less  pretentious  method  of  practice  ?  A  case 
came  under  my  observation  a  short  time  ago  which 
will  illustrate  my  meaning.  A  young  man,  who 
had  been  under  my  own  and  my  brother's  care 
almost  from  childhood,  was  staying  in  New  York 
for  a  time,  and  while  he  was  there  an  upper  molar, 
in  which  my  brother  had  been  trying  to  save  the 
pulp,  began  to  give  the  usual  indications  that  the 
pulp  was  in  a  putrescent  state.  The  patient  was 
well  informed  as  to  what  might  occur,  and  at  once 
sought   advice,   and   obtained   relief  by  the  usual 


TEEATMENT  OP  ADULT  TEETH.        133 

treatment.  When  the  periostitis  was  supposed  to 
be  cured,  the  tooth  was  filled.  But  it  had  been  pre- 
viously filled  in  several  places,  and  it  was  thought 
expedient  to  remove  all  these  fillings,  and  make  one 
grand  gold  filling  of  about  two-thirds  the  crown  of 
the  tooth.  After  all  preparations  were  made,  four 
hours  were  spent  in  packing  the  gold,  by  the 
malleting  process,  and  two  hours  in  finishing  the 
work.  This  proved  to  be  too  much  for  the  poor 
dead  tooth,  and  alveolar  abscess  of  the  most  obsti- 
nate and  persistent  character  was  the  result.  Four 
months  later  he  came  back  io  England,  and  at 
once  came  to  my  brother  for  advice.  Pus  was 
oozing  from  around  all  the  roots,  and  the  probe 
indicated  great  loss  of  bone,  which  indeed  was  quite 
perceptible  to  the  touch  of  the  fingers.  The  tooth 
was  loose  and  sore.  Except  about  the  neck,  it 
was  quite  evident  that  the  alveolus  was  entirely 
destroyed.  Treatment  was  hopeless,  and  as  the 
patient  thought  he  had  borne  with  it  long  enough, 
the  tooth  was  extracted.  I  have  no  doubt  that  if 
this  tooth  had  been  filled  with  amalgam,  it  would 
have  been  a  comfortable,  useful  tooth  for  years ; 
only,  it  is  possible,  somebody  might  have  made  the 
patient  believe  he  was  being  poisoned.  But  it  was  a 
favourable  opportunity  to  show  the  dentist  who 
had  looked  after  this  mouth,  what  beautiful  work 
could  be  done  with  gold,  and  the  patient  was 
undoubtedly  pleased  with  the  idea  of  having  such  a 
piece  of  work  in  his  mouth.  It  was  indeed  a 
beautiful  filling,    but    it    was    time    aud    expense 


134  DENTAL    PRACTICE. 

wasted,  for  it  was  an  utter  failure.  Certainly  this 
was  not  an  instance  where  modern  practice  was  an 
improvement  on  that  of  thirty  years  ago. 

The  rubber  dam  is  very  useful  sometimes ;  but, 
in  a  large  proportion  of  the  cases  one  has  to  treat,  it 
is  unnecessary,  except  for  the  convenience  of  the 
dentist,  because  it  enables  him  to  leave  the  patient, 
without  danger  to  his  work,  and  go  to  his  lunch,  or 
to  see  another  case  for  a  moment.  This  is  a  mani- 
fest injustice  to  the  patient,  who  is  fairly  entitled  to 
be  considered,  and  whose  time  may  be  as  valuable 
as  our  own.  There  are  few  cavities  where  more 
than  fifteen,  twenty,  or  thirty  minutes  will  be 
required  for  packing  the  gold,  and  there  are  not 
many  mouths  where  a  napkin,  properly  arranged, 
will  not  preserve  absolute  dryness  for  that  length  of 
time.  If  the  gum  has  been  wounded,  a  twist  of 
cotton  pressed  up  between  the  gum  and  the  neck  of 
the  tooth,  or  a  little  elastic  band,  cut  from  a  piece 
one-eighth  inch  French  elastic  tubing,  slipped  over 
two  teeth,  or  the  cotton  twist  and  the  elastic  band 
in  conjunction,  will  be  enough  to  stop  any  exuda- 
tion of  blood  or  lymph,  and  certainly  these  are  not 
so  formidable  as  the  way  patients  are  often  gagged 
with  the  rubber  dam.  But  this  is  not  enough  for 
some  operators.  The  "saliva  ejector"  is  fixed  to 
the  mouth — a  sort  of  hydraulic  pump— to  take  away 
the  saliva  as  fast  as  it  is  secreted.  A  "tongue 
depressor"  prevents  any  movement  of  that  organ. 
And  with  all  these  fixtures  in  the  mouth  a  man  may 
go   on  operating  for   hours,   if  he   likes,  or,    as  a 


TREATMENT  OF  ADULT  TEETH.         135 

patient  told  me  a  few  days  ago  of  an  occurrence 
that  happened  to  himself,  he  was  left  with  these 
fixtm-es  in  his  mouth,  and  a  filling  half  completed, 
for  the  ''consultation  hour,"  at  the  expiration  of 
which  the  dentist  came  back  refreshed,  and  resumed 
his  work.  It  cannot  be  said  that  this  is  done  for 
the  good  of  the  patient. 

Again,  there  is  the  mallet,  which  is,  without 
doubt,  a  useful  instrument  sometimes ;  but  it  does 
not  follow,  because  a  little  of  it  is  good,  that  a  great 
deal  must  be  better.  It  is  an  instrument  to  be  used 
with  caution,  because  it  causes  absolute  torture  in 
some  cases,  and  it  cracks  the  enamel  of  many  a 
delicate  tooth ;  yet  it  is  used  persistently  and  con- 
stantly even  in  small  fillings  of  the  size  of  a  pin's 
head,  because  it  saves  the  strength  of  the  dentist. 
This  is  a  reason  good  enough  in  itself  if  it  is  frankly 
admitted,  but  do  not  let  it  be  urged  that  it  is 
entirely  for  the  patient's  benefit.  No  doubt  it 
makes  a  harder  filling  than  is  ordinarily  made  by 
hand-pressure,  but  in  approximal  cavities  it  is  not 
the  hardness  of  the  filling  which  saves  the  tooth.* 

'  The  late  Dr.  Marshall  Webb,  who  was  regarded  as  one  of  the  chief 
Bupportera  of  the  theory  that  teeth  which  can  be  filled  at  all  should  be  filled 
with  gold,  and  that  wedging  and  malleting  are  essential  processes  in  the 
perfecting  of  gold  fillings,  wrote  as  follows  in  a  letter  published  in  the 
Dental  Cosmos  of  January,  1883  ;  a  letter  which  was  evidently  intended  to 
correct  an  extreme  interpretation  of  his  teachings  and  practice  in  the  use  of 
the  mallet,  and  which  is  emphatic  enough  in  condemnation  of  its  indis- 
criminate employment : — "  I  cannot  understand  why  men  whose  judgment 
seems  to  be  so  sound  on  everything  else,  should  in  the  use  of  the  mallet 
display  such  ignorance.  They  say  you  can  pack  more  gold  into  a  given 
cavity  by  the  use  of  the  electric  mallet  than  by  any  other  process.  Just  as 
thongh  it  was  our  aim  to  give  our  patients  the  value  of  their  money  in  gold 


136  DENTAL    PEACTICE. 

I  am  certain  that  the  vitaHty  of  many  a  delicate 
incisor  has  been  destroyed  by  the  "  tap  tap  "  of  the 
mallet.  Every  stroke  is  a  shock,  and,  an  assistant 
being  required  to  use  it,  the  strength  of  the  stroke 
is  not  always  under  the  control  of  the  operator's 
will.  Last,  but  not  least,  the  use  of  the  wedge  is, 
as  I  have  already  shown,  an  abomination,  which 
intensifies  the  torture  of  the  poor  patient  from  all 
the  other  appliances,  and  is  itself  the  least  excus- 
able; for  the  only  object  that  can  be  claimed  for  it  is, 
that  it  may  enable  the  operator  to  restore  a  condi- 
tion of  things  which  led  to  caries,  when  the  tooth 
was  sound,  and  is  to  prevent  it  in  the  restored  state, 
because  the  gold  will  not  decay.  No ;  but  the  gold 
filling  never  was  made  that  was  so  perfect  as  the 
natural  covering  of  the  approximal  surface  of  a 
tooth.  If  there  are  defects  and  fissures  found  by 
the  microscope  in  the  enamel  of  a  tooth,  are  they 
not  also  to  be  found,  by  the  same  means,  around 
the  edges  of  the  most  perfectly  made  filling  ?  I 
contend    that   a   contour    filling  is   liable   to  fail, 


foil,  regardless  of  the  ever-existing  conditions  debarring  us  from  such  a 
course,  and  leading  one  to  suppose  that  the  greatest  good  to  ourselves,  and 
to  those  for  whom  we  operate,  depends  upon  the  greatest  power  we  can 
bring  to  bear  in  crowding  and  cramming  the  precious  metal  into  the  cavity. 
I  believe  rather  that  our  ultimate  success  lies  in  the  reverse  of  this, — that 
is  to  crowd  as  little  as  possible,  bringing  very  little  if  any  pressure  upon  the 
walls  of  the  cavity, — and  in  order  to  do  this  to  use  that  form  of  gold  which 
requires  the  least  force  to  consolidate.  I  think  that  successes  are  ten 
to  one  in  favour  of  this  kind  of  gold,  manipulated  by  hand-pressure  instead 
of  by  the  mallet,  no  matter  how  light  the  blows  may  be.  The  mallet  is  a 
good  thing  in  its  place,  but  it  is,  in  the  majority  of  cases,  out  of  its  place  in 
the  insertion  of  gold  fillings  where  cohesive  gold  is  used  in  the  form  which 
I  have  referred  to."     The  reference  is  to  small  loosely  rolled  gold  cylinders. 


TREATMENT  OF  ADULT  TEETH.        137 

because  it  restores  the  original  form  of  the  tooth, 
and  that,  being  made  after  an  unnatural  inflamma- 
tion has  been  set  up  in  the  socket  by  wedging,  the 
socket  being  at  the  time  widened  so  that  the 
pressure  comes  more  severely  upon  the  end  of 
the  root,  and,  therefore,  upon  the  nerve  where  it 
enters  the  apical  foramen,  the  inflammation  of  the 
peridental  membrane  is  increased  to  a  dangerous 
extent ;  and  that  the  shock  of  the  repeated  strokes 
of  the  mallet  crushes  the  nerve,  so  as  greatly  to 
endanger  the  vitality  of  the  tooth. 

I  cannot  see  that  any  of  these  appliances  are  for 
the  benefit  of  the  patient.  Some  of  them  benefit 
the  dentist,  and  are  at  times  extremely  useful  to 
him ;  but  it  is  an  error  to  think  that  good  work 
cannot  be  done  without  them,  and  it  is  a  greater 
error  to  use  them  because  it  has  become  a  sine  qua 
non  that  a  man  should  make  showy  gold  fillings  if 
he  wishes  to  stand  well  with  his  fellow-practitioners. 
Any  one  who  doubts  that  these  operations  can 
be  done,  and  I  do  not  hesitate  to  say  well  done, 
without  wedging,  and  the  use  of  the  rubber  dam 
and  mallet,  I  would  ask  to  look  at  Fig.  39,  page  84, 
which  gives  a  very  good  idea  of  the  extent  of  the 
fillings  in  what  may  be  described  as  a  very  wet 
mouth.  I  made  all  the  approximal  fillings  in  both 
sides  of  the  incisors,  canine  and  two  bicuspids,  by 
the  method  I  have  described  as  a  combination  of 
soft  and  cohesive  gold.  One  of  the  laterals  was  so 
seriously  decayed  that  a  part  of  the  labial  wall  was 
broken  down,  and  the  lip  covering  the  tooth  well, 


138  DENTAL    PRACTICE. 

I  restored  the  contour.     All  this  was  done  without 
using  wedge,  or  rubber  dam,  or  mallet. 

The  following  extract  from  a  letter  to  the  late 
Dr.  Eobert  Arthur,  printed  as  a  foot-note,  on  page 
141  of  his  work  on  the  Treatment  and  Prevention  of 
Decay  of  the  Teeth,  is  a  frank  acknowledgment  of 
what  must  occur  in  the  practice  of  every  man  who 
persistently  pursues  this  course  of  treatment,  but 
not  many  of  them  are  ready  to  admit  their 
failures: — "I  have  to  deplore  the  comparative 
failure  of  some  of  the  most  perfect  and  beautiful 
fillings,  that  cost  me  hours  and  days  of  patient 
painstaking  labour.  I  particularly  refer  to  those 
cases  where  the  teeth  were  ivedged'^  apart,  carefully 
and  perfectly  filled,  without  making  a  file  scratch 
upon  the  proximate  surfaces,  and  then  allowed  to 
drop  back  to  their  natural  positions.  Dr.  Eleazer 
Parmly,  of  New  York,  paid  one  such  of  my  cases 
the  compliment  of  saying  it  presented  the  most  per- 
fect specimens  of  proximate  filling  he  had  ever  seen, 
and  yet,  although  the  patient  was  an  attentive  and 
appreciative  one,  who  was  fully  instructed,  and 
spared  no  pains  in  the  care  of  her  teeth,  decay, 
after  a  few  years,  commenced  around  the  edges  of 
the  fillings.  I  had  to  file  the  spaces  so  that  the 
teeth  were  permanently  separated,  and  refill  all  the 
cavities.  This  is  only  one  very  marked  case  in 
my  experience.  Many,  very  many,  others  have 
occurred  in  my  practice,  and  came  under  my 
observation." 

c  '      -  *  The  italics  are  his  own.  — ^ 


TREATMENT  OF  ADULT  TEETH.         13^ 

I  have  just  had  my  attention  recalled  to  a  case 
that  came  into  my  hands  two  or  three  years  ago. 
A  lady  was  suffering  from  alveolar  abscess,  caused 
by  a  dead  pulp  in  one  of  the  upper  central  incisors, 
and  she  told  me  that  she  has  been  constantly 
troubled  with  her  front  teeth  for  several  years  ; 
indeed,  they  were  dreadfully  painful  when  they  were 
filled,  and  had  been  more  or  less  troublesome  ever 
since.  She  had  a  great  deal  of  good  work  in  her 
mouth,  and  the  larger  part  of  the  fihings  were  saving 
the  teeth.  The  two  central  incisors  had  fillings  in 
the  mesial  surfaces,  and  both  teeth  were  dead,  but 
there  was  nothing  in  the  appearance  of  the  fillings  to 
justify  me  in  removing  them.  So  I  drilled  into  the 
pulp  cavities  from  the  lingual  surfaces,  found 
putrescent  pulps,  as  I  expected,  removed  them,  or 
the  remains  of  them,  treated  the  roots  with  anti- 
septics until  they  were  clean  and  healthy,  and  then 
filled  them.  She  told  me  that  the  teeth  had  been 
wedged  apart  when  she  was  about  thirteen  years 
old,  and  filled  then  with  gold;  that  she  suffered 
dreadfully  when  it  was  being  done,  and  for  weeks 
after  ;  that  then  there  was  a  period  of  comfort  with 
them,  and  afterwards  she  began  to  have  a  swollen 
face  every  time  she  was  exposed  to  cold.  This  is  a 
common  history,  such  as  we  have  all  heard  over 
and  over  again.  Of  course  it  is  impossible  to  say 
whether  the  vitality  of  these  two  teeth  was  destroyed 
by  wedging,  or  by  the  mere  insertion  of  the  metallic 
fillings  on  a  sensitive  surface,  and  the  consequent 
frequent  shocks  from  thermal  changes.  But  whether 


140  DENTAL    PRACTICE. 

it  was  by  one  or  the  other,  or  by  both  combined, 
the  mischief  was  certainly  to  be  traced  to  the 
filHngs,  and  as  certainly  it  would  not  have  occurred 
if  the  cavities  had  been  excavated,  without  wedging, 
from  the  lingual  surfaces,  and  filled  with  gutta- 
percha until  the  patient  was  a  few  years  older.  I 
have  seen  the  lady  again  quite  recently.  She  had 
not  suffered  again  from  swollen  face,  but  one  of  the 
teeth  had  begun  to  decay  around  the  edge  of  the 
approximal  filling,  and  I  had  to  refill  it.  This 
gave  me  an  opportunity  of  satisfying  myself  about 
what  I  had  before  only  suspected,  viz.,  that  the 
original  cavity  had  not  penetrated  so  deeply  into 
the  tooth  as  to  affect  the  pulp. 

The  history  of  our  professional  progress  in  the 
last  decade  shows  how  men,  who  labour  for  the 
profession,  may  be  misunderstood  and  misrepre- 
sented, as  in  the  case  of  Dr.  Foster  Flagg,  who  has 
devoted  these  later  years  to  an  effort  to  lift  our 
specialty  out  of  a  narrow  groove,  and  give  its 
practitioners  the  broader  views  which  should  dis- 
tinguish professional  men.  To  do  this  more 
effectually,  he  refuses  to  treat  those  teeth  which  can 
be  saved  by  gold  fillings,  and  devotes  himself  solely 
to  the  saving  of  teeth  which  the  gold  workers  would 
consider  hopeless  from  their  point  of  view.  He 
uses  only  the  plastic  materials  which  those  workers 
in  precious  metals  affect  to  despise,  and  does  more 
than  any  other  man  has  ever  done  to  improve  the 
character  and  preparation  of  these  materials.  He 
sacrifices  the  credit  which  the  profession  gives  to 


TKEATMENT  OF  ADULT  TEETH.        141 

men  who  do  only  one  kind  of  work  well,  the  profit 
from   cases   which   make   a   great   show  with   the 
exj^enditure   of  mere   mechanical   skill,    and     also 
valuable  time  in  analysing,  testing,  and  preparing 
alloys  and  mixtures,  the  results  of  which  he  freely 
gives  to  the  profession.     Yet  a  large  proportion  of 
the   members   of  the   profession  he   thus   tries  to 
advance,  impute  the  basest  motives  of  self-interest 
to  his  efforts,  and  apply  an  epithet,  which  is  a  pun 
upon  his  name,  to  those  who  try  to  benefit  by  his 
teachings,  without  following  his  extreme  example, 
which  he  never  suggested  or  expected  that  any  one 
would  do.      So  it  may  be  that  some  who  read  these 
notes  will  misconstrue  my  meaning,  and  say  that  I 
am  endeavouring  to  create  a  prejudice  against  the 
use  of  gold  for  filling  teeth ;    but  I  emphatically 
deny  that  I  have  any  wish  or  intention  to  say  a 
word  against  the  use  of  gold  in  the  abstract.     I  do, 
however,  mean  to  protest  against  what  I  consider 
to   be  a  growing  evil  in  our  profession,  viz.,  the 
measuring  of  a  man's  ability  as  a  dentist  by  the 
amount  of  labour  he  bestows  upon  one  particular 
kind  of  work,  and  the  consequent  tendency  of  the 
teaching  and  practice  of  dentists  to  devote  all  their 
energies  to   the    making   of  gold  fillings,    without 
sufiQcient  consideration  for  the  comfort  or  the  time 
of  their  patients,  and  without  exercising  a  reason- 
able amount  of  judgment  as  to  whether  the  case  is 
a  suitable  one  for  that  form  of  treatment :  thereby 
incurring  risk  of  failure  of  the  operation  after  the 
endurance  and  the  purse  of  the  patient  have  been 


142  DENTAL    PRACTICE. 

severely  taxed,  with  the  inevitable  result  that  con- 
fidence in  our  operations  is  destroyed,  and  our 
power  to  do  good  diminished.  It  amounts  to  this, 
that  if  a  man  does  not  treat  all  his  cases  alike, 
whether  it  be  child  or  youth ;  a  young,  middle-aged, 
or  elderly  man  or  woman ;  whether  a  woman  be 
married  or  single,  having  a  child  every  year  or  two, 
or  having  none  ;  delicate,  sickly  and  nervous,  or 
vigorous,  healthy,  and  knowing  nothing  of  nerves ; 
if  he  thinks  it  best  to  use  plastic  fillings  for  some  of 
these — no  matter  how  much  he  may  use  gold  for 
suitable  cases — he  is  liable,  if  his  work  is  seen  by 
those  who  claim  to  be  the  regular  practitioners,  to 
have  his  practice  condemned,  and  his  claim  to 
position  in  the  profession  disallowed.  It  is,  there- 
fore, quite  time  for  thinking  men  to  assert  them- 
selves, and  to  do  all  that  lies  in  their  power  to 
assist  in  the  dissemination  of  more  liberal  and 
eclectic  ideas.  The  doctor  with  one  medicine  for 
every  ill  is  a  quack,  and  the  dentist  who  has  but 
one  idea  is  no  better;  but,  naturally  enough,  if  a 
man's  standing  in  his  profession  is  to  be  judged 
solely  by  his  skill  in  one  kind  of  work  he  will  not 
think  of  anything  else ;  and  so  long  as  he  can  per- 
suade his  patients  to  submit,  he  will  take  advantage 
of  every  aid  which  inventive  talent  can  provide,  to 
perfect  that  kind  of  work ;  and  he  is  unwilling  to 
admit  that  another  man  can  get  as  good  results  by 
more  simple  means.  But,  after  all,  it  is  the  result 
that  we  judge  ourselves  by,  and  if  a  man  satisfies 
hinaself,  he  cannot  go  very  far  wrong.  - 


TREATMENT  OF  ADULT  TEETH.        143 

I  have  written  to  little  purpose,  however,  if  I 
have  conveyed  an  impression  that  I  think  thorough- 
ness is  not  essential  in  an  operator.  The  aim 
should  be  to  reach  perfection  of  work;  but  it  does 
not  depend  solely  on  ourselves,  and  we  cannot 
attain  it  at  once  in  every  case.  We  shall  have 
nervous  and  weakly  children  to  treat,  or  pregnant 
women,  whose  teeth  are  too  sensitive  to  bear  even  a 
breath  of  cold  air  without  causing  pain  ;  or  men 
and  women  recovering  from  severe  illnesses,  when 
their  weakness  is  both  a  cause  of  sensitiveness,  and 
a  reason  why  they  cannot  endure  thoroughness  of 
treatment.  In  these  cases,  if  we  can,  without 
attempting  to  remove  all,  or  even  any  of  the  newly 
decalcified  dentine,  so  shape  the  space  between 
two  decaying  teeth  that  gutta-percha  can  be  re- 
tained in  contact  with  both  surfaces,  we  shall  have 
gained  a  step.  Even  an  operation  so  slight  as  this 
may  give  comfort  to  a  sufferer,  as  well  as  check  the 
ravages  of  decay,  while  an  attempt  at  thorough  ex- 
cavation would  probably  drive  the  patient  out  of  the 
chair,  or  cause  a  sacrifice  of  valuable  teeth.  Protec- 
tion of  carious  surfaces,  no  more  thorough  than 
that  just  indicated,  will  in  a  short  time  make  it 
possible  to  excavate  more  thoroughly,  and  so,  in 
time,  a  proper  filling  may  be  possible.  But  it  must 
not  be  supposed,  because  a  man  tries  to  make  an 
operation  bearable  to  his  patient,  and  attain  perfec- 
tion of  work  by  stages  that  are  easy,  not  so  much 
for  himself  as  for  those  who  seek  relief  at  his 
hands,  that  he  will  be  content  with  the  result  before 


144  DENTAL    PEACTICE. 

perfection  is  attained.  Perhaps  it  is  too  much  to 
expect  of  human  nature  that  a  man  will  try  to  put 
himself  in  the  place  of  his  rival,  as  Charles  Eeade's 
Dr.  Amboyne  might  suggest ;  but  if  we  could, 
when  we  see  a  patient  who  has  had  this  kind  of 
treatment  at  the  hands  of  our  neighbour,  try  to 
realise  the  circumstances  under  which  the  opera- 
tions were  performed,  and  not  say,  with  an  expres- 
sion of  wonder  at  the  incapacity  of  the  operator, 
and  of  pity  for  the  victim,  that  we  cannot  see  why 
the  work  was  not  more  thoroughly  done,  it  might 
help  us  to  a  better  position,  as  professional  men, 
in  the  estimation  of  the  public,  and  certainly  it 
would  give   us  more  self-respect. 

We  may  put  a  young  man's  teeth  in  order,  and, 
if  he  is  vigorous  and  strong,  it  may  be  quite  pos- 
sible that  he  will  not  need  the  services  of  a  dentist 
again  until  he  is  past  the  prime  of  life ;  but  a  young 
woman,  with  equally  good  work  in  her  mouth,  has 
not  the  same  chance  of  reaching  middle  age  without 
requiring  more  or  less  of  the  dentist's  aid;  for 
although  good  work  may  make  the  teeth  as  safe 
from  new  decay  as  if  they  had  never  decayed  at  all, 
it  cannot  make  them  better  than  this.  The  young 
woman  gets  married,  and  has  a  family  of  children. 
During  pregnancy  she  suffers  from  acidity,  which 
attacks  her  teeth  to  such  an  extent  that  she  often 
despairs  of  saving  any  of  them.  Perhaps  in  her 
despair  she  relaxes  her  efforts  to  neutralise  the 
acids  and  keep  her  teeth  clean,  when  at  such  time 
she  should  redouble,  and  if  necessary,  quadruple, 


TREATMENT  OF  ADULT  TEETH.        145 

her  exertions.  Of  course  we  can  do  but  little  if 
she  will  not  try  to  help  herself;  but  to  those  who  do 
try,  are  we  to  give  no  help  at  all,  because  the  teeth 
are  too  sensitive  to  bear  the  excavating  for  gold,  or 
because,  when  the  teeth  are  filled  with  gold  to  the 
best  of  our  ability,  the  fillings  fail  ?  I  do  not  think 
it  would  be  dentistry  in  the  highest  sense,  if  we 
could  not  do  something  for  her.  It  is  possible  to 
keep  the  teeth  for  ten,  or  twenty  years,  if  necessary, 
with  gutta-percha  fillings,  renewing  them  as  often 
as  may  be  needful ;  and|then,  when  this  temporary 
work  is  no  longer  requisite,  we  may  do  as  much 
gold  work  as  may  be  necessary.  But  to  put  it  on 
the  low  ground  of  policy  alone,  without  reference 
to  the  patient's  ability  to  bear  pain,  I  doubt  if  it  is 
best  to  attemj)t  to  do  the  permanent  work  until  we 
see  the  last  of  the  babies. 

The  cervical  edge  of  a  filling  that  extends 
under  the  gum,  is^always  a  weak  spot ;  and  I  have 
very  little  confidence  in  the  safety  of  gold  in  that 
position.  I  therefore  generally  commence  a  filling 
in  that  position  with  gutta-percha,  if  much  of  the 
cavity  is  under  the  gum,  or  with  tin,  if  it  is  only 
slightly  so.  Tin  never  loses  its  compressibility, 
until  it  is  hard  and  dense  throughout ;  gold,  on  the 
contrary,  may  become  hard  on  the  surface  from 
packing,  and  perfectly  soft  beneath.  Therefore,  in 
packing  a  filling  into  a  position  that  we  cannot  see 
all  the  time  the  instrument  is  at  work,  it  is  possible 
to  leave  a  corner  loosely  packed ;  but  with  a  few  folds 
of  tin  foil  beneath  the  gold  this  is  not  so  likely  to 

E 


146  DENTAL    PRACTICE. 

occur,  as  the  tin  will  still  be  condensed,  while  the 
gold  is  being  packed  down  upon  it.  In  these 
positions,  where  the  slightest  deviation  of  the  instru- 
ment from  its  proper  direction  may  flood  the  cavity 
with  blood,  it  is  a  help  to  leave  the  tin  projecting  so 
as  to  overlie  the  gum,  and  we  can  condense  this  por- 
tion of  the  filling  more  thoroughly  when  the  gold  is 
completely  packed,  and  thus  make  a  tight  joint  after 
the  risk  of  flooding  is  past.  I  have  had,  in  the 
course  of  my  professional  experience,  the  opportunity 
of  examining  a  great  many  fillings  in  which  gold  and 
tin  were  used  in  combination, — the  work  of  a  man 
long  since  dead, — and  there  was  certainly  no  ill  result 
in  any  one  instance  from  the  contact  of  the  two  metals 
in  the  same  cavity.  If  any  failure  of  the  fillings 
occurred,  it  was  more  frequently  the  gold  that  failed 
than  the  tin,  because  the  gold  had  to  stand  the  wear 
of  mastication,  and  the  cohesive  quality  of  this  metal 
had  never  been  utilized  to  give  a  harder  surface  to 
any  of  the  fillings.  Tin  makes  an  extremely  good 
filling.  It  appears  to  have  a  better  preservative 
effect  upon  the  surface  of  dentine  with  which  it  is 
in  contact  than  gold,  but  it  can  never  be  hard 
enough  to  wear  as  gold  does  if  properly  packed. 
This  is,  however,  an  objection  which  only  applies 
in  cavities  which  are  actually  exposed  to  the  attrition 
of  mastication.  When  tin  is  placed  against  the 
cervical  wall  in  approximal  cavities,  and  the  bulk  of 
the  cavity  filled  with  gold,  all  its  best  qualities  are 
available  without  its  disadvantages.  But  care  must 
be  taken  that  it  is  not  packed  in  contact  with  the 


TREATMENT  OF  ADULT  TEETH.        147 

labial  wall  of  a  frout  tooth,  as  it  will  show  dis- 
colouration, which,  however,  the  thinnest  fold  of 
gold  in  that  corner  of  the  cavity  will  prevent. 
Before  the  tin  is  quite  fully  condensed,  a  twist  of 
gold  should  be  packed  into  it,  and  then  packed 
down  with  it,  so  as  to  leave  a  surface  of  gold,  and 
then  the  filling  may  be  proceeded  with  exactly  as  in 
the  case  of  soft  and  cohesive  gold  fillings  previously 
described.  When  gutta-percha  is  used  for  that  por- 
tion of  the  cavity  which  is  under  the  gum,  it  is,  of 
course,  still  soft  enough  to  be  compressed  by  the 
packing  of  the  gold,  and  it  makes  as  tight  a  joint  as 
can  perhaps  be  made,  and  as  it  is  perfectly  pro- 
tected from  attrition,  it  is  practically  indestructible. 
For  approximal  cavities  in  bicuspids  and  molars, 
which,  as  every  dentist  knows,  are  extremely  liable 
to  fail  at  the  cervical  edge,  if  they  are  to  the  slightest 
extent  under  the  gum,  the  use  of  tin,  or  gutta- 
percha, as  a  foundation,  makes  safer  work  than 
can  be  made  by  trusting  to  gold  alone. 

A  case  came  into  my  hands  about  three  or  four 
years  ago,  where  the  palatine  cusp  of  an  upper 
second  bicuspid  had  been  broken  away,  the  fracture 
extending  under  the  gum.  It  had  been  restored 
with  gold,  making  a  very  nice  looking  operation, 
but  the  patient  told  me  it  was  a  very  laborious  one, 
as  the  operator  had  spent  about  six  hours  in 
packing  and  finishing  the  filling.  A  few  months 
after  I  first  saw  the  case,  and  admired  its  appear- 
ance— much  to  the  patient's  satisfaction,  as  he 
thought  it  a  very  good  piece  of  work — he  called  to 


148  DENTAL    PRACTICE. 

ask  me  to  look  at  his  big  filling,  which  he  fancied 
was  becoming  loose.  An  examination  showed  that 
he  was  quite  correct,  as  the  whole  mass  of  gold 
came  away  without  the  application  of  any  force. 
The  failure  was  due  to  some  slight  decay — very 
slight  it  was — at  the  point  where  the  anchorage  for 
the  gold  had  been  made  under  the  gum.  The 
question  then  arose,  How  could  the  mischief  be 
remedied  so  as  to  make  the  tooth  safe  and  useful  ? 
My  own  preference  would  have  been  to  make  a  new 
cusp  of  porcelain,  and  fill  in  the  space  between  that 
and  the  natural  cusp  with  amalgam,  a  process 
which  I  will  explain  later  on,  but  the  patient  was 
desirous  that  gold  should  be  tried  once  more. 
Being  satisfied  that  it  would  not  be  safe  to  make 
another  filling  like  that  which  had  failed,  I  deter- 
mined to  build  down  the  cusp  around  a  gold  pin 
fixed  in  the  root,  and  on  a  foundation  of  gutta- 
percha. I  therefore  proceeded  to  drill  the  root ; 
that  is,  to  enlarge  the  pulp  canal,  so  that  it  would 
take  the  gold  wire  which  is  used  for  the  English 
tube  teeth,  and  this  enlargement  of  the  canal  I 
carried  as  deeply  as  I  dared  go  without  perforation 
of  the  side  of  the  root,  feeling  my  way  carefully  by 
using  drills  that  were  each  a  trifle  larger  than  the 
preceding  one,  and  watching  for  any  indication  of 
sensibility  to  show  that  I  was  getting  too  near  the 
peridental  membrane.  Then  fitting  my  wire,  I  cut  it 
to  the  exact  length  that  would  allow  it  to  touch  and 
take  the  bite  of  the  lower  tooth,  when  the  mouth  was 
closed  with  the  wire  in  position.    I  then  fitted  a  sort 


TKEATMENT  OF  ADULT  TEETH.        149 

of  half-hoop  of  eighteen  carat  gold  to  the  broken 
edge  of  the  root  that  was  beneath  the  gum,  making 
it  wide  enough  to  extend  slightly  beyond  the  margin 
of  the  gum.  This  I  soldered  by  a  connecting  stud 
on  either  side  to  the  wire.  All  this  work  was  done 
upon  a  plaster  model  in  the  workroom.  Finding 
that  this  gold  work  fitted  properly,  when  tried  in 
the  mouth,  the  next  step  was  to  fix  the  wire  in  the 
root,  which  was  done  by  barbing  it  on  four  sides 
with  a  strong  knife,  and  then  pressing  it  up  into  the 
root  with  a  little  stiff  sandarac  varnish  to  act  as  a 
cement.  I  then  packed  the  half-hoop  nearly  full  of 
gutta-percha,  taking  care  to  make  a  tight  joint 
where  the  hoop  fitted  the  surface  of  the  root.  On 
this  foundation  I  built  down  the  gold  cusp,  my 
retaining  points  being  the  half-hoop,  the  wire,  and 
the  remaining  natural  cusp.  The  fixing  of  the  wire 
and  half-hoop,  the  packing  of  the  gutta-percha,  and 
finally,  the  packing  of  the  gold,  took  altogether  less 
than  an  hour  of  my  time.  The  gold  was  packed  by 
hand-pressure.  The  rubber  dam  was  not  used,  and 
a  napkin  sufficed  to  keep  the  work  dry.  The  patient 
sat  low  and  comfortably  in  the  chair,  not  as  though 
lying  on  a  surgeon's  operating  table,  and  the  work 
was  wholly  done  by  reflection  from  my  little  mirror, 
without  stooping  or  discomfort  on  my  own  part ; 
and  it  is  standing  perfectly  well  at  the  present  time, 
as  I  recently  had  an  opportunity  of  seeing,  three 
years  after  the  operation  was  completed. 

Cavities  in  the  grinding  surfaces  of  molars,  and 
in  the  sulci  between  the  cusps  of  bicuspids,   are 


150  DENTAL    PRACTICE. 

simple  enough,  unless,  from  neglect,  their  walls  are 
allowed  to  become  too  weak  to  stand  the  packing  of 
gold  fillings.  It  is  a  common  practice,  however,  to 
prepare  all  such  cavities  by  simply  driving  a  rose 
drill  into  them,  and  then  inserting  the  filling.  This 
is  a  rough  and  ready  way  of  preparing  for  a  failure, 
unless  the  drill  is  unnecessarily  large,  for  such 
cavities  are  never  cylindrical  in  shape,  and  a  drill 
will  either  not  cut  out  enough  to  make  the  filling 
safe,  or  it  will  cut  away  too  much  sound  dentine. 
It  is  perhaps  well  enough  to  open  a  cavity  of  this 
description  with  a  drill,  but  it  should  never  be 
considered  ready  for  a  filling  until  all  the  fissures 
radiating  from  it  are  cut  out,  which  may  be  done 
with  fissure  drills,  or  with  a  narrow  enamel  chisel. 
My  own  practice  is  to  open  all  these  cavities  with  a 
chisel,  feeling  the  depth  and  extent  of  the  decay, 
and  noting  the  course  of  the  fissures  which  are  to  be 
cut  out  after  I  have  ascertained  the  nature  of  the 
cavity,  when  the  fissure  drills  may  be  very  useful. 
I  find  this  a  safer  course,  as  one  will  sometimes 
meet  with  a  case  where,  after  cutting  away  a  com- 
paratively strong  substance  of  enamel,  the  drill  will 
plunge  suddenly  into  a  soft  and  sensitive  dentine,  to 
the  great  discomfort  and  alarm  of  the  patient ;  and 
all  this  is  better  to  be  avoided  if  possible.  Not 
infrequently  there  will  be  two  or  three  of  these 
cavities  in  a  grinding  surface,  and  they  may  be 
connected  by  narrow  fissures,  or  possibly,  but  more 
rarely,  they  may  be  separated  by  perfectly  sound, 
well  calcified  enamel.     There  cannot,  however,  be 


TREATMENT  OF  ADULT  TEETH.        151 

any  doubt  on  this  point  in  the  mind  of  a  careful  and 
observant  operator.  The  fissures  can  be  seen,  if 
they  exist  to  endanger  the  fillings,  and  they  must 
be  cut  out  as  far  as  they  can  be  seen  to  extend.  It 
is  quite  unnecessary  to  make  under  cuttings,  or 
retaining  points,  in  cavities  of  this  nature.  The 
walls  may  be  parallel,  or  even  in  parts  slightly 
sloping  outwards,  and  well-packed  gold  fillings  will 
never  move.  Cavities  of  this  class  are,  I  consider, 
the  only  ones  where  the  use  of  the  mallet  is  justi- 
fiable. If  the  walls  are  strong,  that  is,  if  there  is  a 
good  substance  of  dentine,  as  well  as  of  enamel,  and 
there  is  no  irritation  in  the  socket,  either  from 
diseased  pulp  or  unnatural  pressure,  the  mallet  may 
be  very  useful  in  attaining  that  degree  of  hardness 
and  density  which  is  most  desirable  in  fillings  that 
wiU  be  subjected  to  the  direct  wear  of  mastication, 
and  which,  as  all  operators  are  not  equally  endowed 
with  a  good  physique,  may  not  be  attainable  by 
mere  wrist  strength.  If,  however,  any  one  of  the 
walls  is  weak,  if  it  is  of  enamel  unsupported  by 
dentine,  the  mallet  should  never  be  allowed  to  touch 
a  plugger  in  that  locality,  as  the  suddenly -applied 
force  will  crack  the  enamel  in  every  direction,  and 
leave  it  liable  to  crumble  and  break  down  after  the 
filling  is  completed.  I  prefer  to  fill  all  such  cavities 
two -thirds  or  three-quarters  full  with  soft  gold, 
and  then  finish  with  cohesive  gold,  as  this  gives 
greater  hardness  of  surface  than  is  possible  with 
soft  gold  alone.  If  the  cavities  are  deep  and 
dangerously  near  the  pulp  at  any  point,  it  is  a  safe 


152  DENTAL    PEACTICE. 

precaution  to  pack  a  lining  of  gutta-percha  in  that 
portion  of  the  cavity  (taking  care  that  the  pressure 
shall  not  be  directly  towards  the  pulp)  and,  when 
this  is  hard,  complete  with  gold.  The  gutta-percha 
will  save  the  pulp  from  the  shock  which  it  might 
be  subjected  to  from  hot  or  cold  drinks,  or  food,  if 
the  gold,  with  its  quick  conducting  nature,  were  in 
close  proximity  to  it. 

In  the  description  of  the  process  of  making  and 
fitting  gold  cups  and  gutta-percha  fillings,  quoted 
from  Dr.  Essig,  on  page  30,  that  author  mentions 
a  case  which  had  come  under  his  observation, 
where  a  gutta-percha  filling  had  lasted  fifteen  years 
in  a  position  not  exposed  to  much  attrition.  It  is 
not  by  any  means  an  exceptional  case,  but  I  wonder 
how  many  of  our  experienced  operators  (I  use  the 
word  "experienced"  because  those  who  are  not 
so  qualified  to  form  an  opinion  are  usually  too 
sanguine  to  put  any  limit  to  the  durability  of  their 
work)  would  not  be  glad  to  be  assured  that  the 
gold  fillings  they  make  in  positions  which  are  not 
exposed  to  much  wear  from  mastication,  would  last 
as  long.  It  is  in  such  situations  that  gutta-percha 
makes  a  safer,  and  certainly  a  more  comfortable 
filling  than  can  be  made  with  gold,  however  well 
the  work  may  be  done.  I  do  not  by  any  means 
advocate  the  use  of  gutta-percha  as  an  unprotected 
permanent  filling  in  situations  where  a  soft  material 
must  of  necessity  be  worn  away  rapidly.  Gold 
fiUings  very  rarely  fail  in  the  grinding  surfaces  of 
molars  and  bicuspids,  or  in  the  lingual  surfaces  of 


TREATMENT  OF  ADULT  TEETH.        153 

canines  and  incisors,  where  they  are  always  exposed 
to  attrition  in  some  form.  It  is  in  the  nooks  and 
corners,  which  are  not  exposed  to  natural  friction, 
that  we  are  to  look  for  failure,  and  it  is  in  these 
places  that  we  shall  often  find  gutta-percha  more 
valuable  than  gold  as  a  barrier  to  the  ravages  of 
decay.  Constant  attrition  is  a  great  safeguard  to 
the  teeth  in  preventing  decay,  and,  if  all  their 
surfaces  were  alike  exposed  to  it,  the  work  of  the 
dentist  would  be  greatly  simplified,  if  not  rendered 
altogether  unnecessary. 

Another  class  of  cavities  are  those  which  are 
found  at  the  necks  of  the  teeth,  on  the  labial 
and  buccal  surfaces.  Caries  of  this  description 
may  affect  any  or  all  of  the  teeth,  upper  and 
lower,  but  it  is  rarely  seen  in  youth,  while 
the  gums  retain  their  natural  position  and  adhe- 
sion to  the  teeth  in  a  line  exactly  corresponding 
to  the  cervical  termination  of  the  enamel.  But 
when,  from  neglect,  a  formation  of  calculus  has 
been  allowed  to  accumulate  at  the  neck  of  the 
tooth,  forcing  the  gum  back,  and  destroying  the 
thin  edge  of  alveolus  which  gives  the  gum  its 
form  ;  or  when,  on  the  other  hand,  the  efforts  at 
cleanliness  have  been  too  severe,  and  hard  brushing 
that  would  have  been  more  suitable  for  fire-irons 
and  fenders  than  for  flesh  and  blood  structures,  has 
worn  away  the  delicate  covering  of  the  dentine  in 
this  locality,  and  the  tooth  is  left  without  its 
natural  protection,  it  is  only  too  well  prepared  to 
suffer  from  any  abnormal  condition  of  the  mucous 


154  DENTAL    PRACTICE. 

secretion  which,  from  a  variety  of  constitutional 
causes,  may  become  so  acidulated  as  to  overpower 
the  neutraHzing  effect  of  the  sahva.  This  condition 
of  the  mucous  secretion  may  arise  from  indigestion, 
from  hepatic  derangements,  from  uterine  affections 
of  every  nature,  or  from  any  protracted  disturbance 
of  the  mucous  membrane  and  the  sympathetic 
nervous  system.  We  have,  however,  more  to  do 
with  the  effect  than  with  the  cause.  When  we  have 
a  condition  of  this  nature  to  deal  with,  we  may  find 
decay  progressing  so  rapidly,  that  deep  cavities 
with  well-defined  walls  are  developed  in  a  few 
months,  or  the  progress  may  be  slow,  and,  as  the 
dentine  is  softened,  the  brush  will  wear  it  away, 
and  the  lesion  will  gradually  assume  an  appearance 
as  if  a  round  file  had  been  used  to  cut  a  groove 
across  the  necks  of  the  teeth,  and  the  surfaces  had 
then  been  carefully  polished.  In  the  latter  case 
there  is  little  need  for  anxiety,  for  the  causes  which 
have  operated  so  slowly  may  cease  to  act,  and  the 
teeth,  though  disfigured,  be  safe  for  years ;  but,  if 
the  disease  is  making  sufficiently  rapid  progress  to 
form  a  definite  cavity,  it  must  be  checked  as  quickly 
as  possible.  Like  all  other  cases  of  dental  caries, 
but,  perhaps,  to  a  more  marked  degree  in  these,  the 
rapidity  with  which  the  disease  progresses  regulates 
the  sensibility ;  and  in  many  such  cases  it  is  not  so 
much  a  question  what  is  best  to  be  used  for  fillings, 
as  what  is  possible.  When  the  cavities  are  so 
sensitive  that  it  seems  to  be  absolute  cruelty  to  be 
thorough,  I   have  always   found  that   such   slight 


TREATMENT  OF  ADULT  TEETH.        155 

excavation,  as  can  be  done  in  a  few  seconds  with  a 
sharp  excavator,  will  enable  me  to  put  in  a  gutta- 
percha filling  which  will  so  effectually  check  the 
disease,  that  in  a  few  months  it  may  be  quite 
possible,  if  it  is  desirable,  to  fill  them  with  gold 
without  any  unbearable  pain.  Or  if,  as  will  often 
be  the  case,  the  dentine  is  still  too  sensitive  to  bear 
gold  with  comfort,  such  a  gutta-percha  filling  may 
be  made  that  it  will  last  five  or  six  years,  and  give 
more  comfort,  and,  I  think,  more  security  too,  than 
gold  will  ever  give  on  a  very  sensitive  surface.  It 
is  an  error  to  suppose  that  any  rough  work  is  good 
enough  for  gutta-percha.  A  filling  may  certainly  be 
made  with  this  material  in  a  few  minutes,  and  yet 
be  sufficient  to  check  the  rapid  progress  of  decay  so 
as  to  allay  an  intolerable  sensibility  of  a  decaying 
surface ;  but  quick  work  does  not  necessarily  mean 
rough,  or  bad  work.  A  few  quick  strokes  with 
well -selected  instruments,  and  a  firm  hand,  guided 
by  a  sure  knowledge  of  how  and  where  to  cut,  may 
shape  a  cavity  that  will  retain  for  months  a  gutta- 
percha stopping  sufficiently  impermeable  for  this 
purpose.  When,  however,  it  is  possible  to  do  so, 
careful  excavation  and  careful  packing,  with  fine 
points,  is  as  necessary  to  ensure  durability  with  this 
material  as  with  gold. 

When  the  rapid  progress  of  decay  has  been 
stopped,  and  when  the  surface  of  the  dentine  has 
regained  its  normal  state  of  comparative  insensi- 
bility, there  can  be  no  doubt  that  it  is  best  to  fill  all 
cavities  of  the  class  under  discussion,  as  far  back 


156  DENTAL    PRACTICE. 

at  least  as  the  second  bicuspid,  with  gold.  For 
molars,  however,  when  we  consider  the  difficulty  of 
keeping  such  cavities  dry  long  enough  to  pack  a 
good  gold  filling,  even  with  the  rubber  dam,  and 
the  difficulty  of  applying  the  rubber  dam  to  be 
useful  in  such  a  locality,  without  "  dissecting  away 
the  gum " — as  a  dentist  once  coolly  told  me  he 
did  in  such  cases,  without  any  idea  that  he  was 
talking  of  such  a  dreadful  thing  as  vivisection — I 
doubt  whether  it  is  not  best  to  be  content  with  the 
degree  of  permanency  that  can  be  got  from  gutta- 
percha, more  especially  if  the  lesion  is  extensive. 
These  cavities  usually  extend  under  the  margin  of 
the  gum,  and,  if  gold  is  to  be  used,  it  is  of  the 
utmost  importance  to  make  sure  of  clean  excava- 
tion there.  If  the  operator  is  not  confident  of  his 
ability  to  excavate  without  touching  the  gum  with 
his  instruments,  he  must  cut  the  gum  away,  and 
after  placing  a  proper  clamp  or  clamps,  apply  the 
rubber  dam,  but  as  all  this  adds  immensely  to  the 
formidable  nature  of  the  operation,  it  is  better,  if 
one  can,  to  train  the  eye  and  hand  to  work  without 
these  appliances.  This  certainly  can  be  done,  for  I 
have  never  cut  away  the  gum  to  fill  a  cavity  of  this 
nature.  I  have  often  found  the  gum  growing  over 
the  edge  of  such  a  cavity,  perhaps  filling  it,  so  that 
it  required  to  be  pressed  back ;  but  these  were  dead 
teeth  almost  invariably,  and  the  necessary  course  of 
dressings  has  always  enabled  me  to  get  the  gum 
out  of  the  way  without  cutting.  If  the  cavity 
extended  far  under  the  margin  of  the  gum,  I  have 


TREATMENT  OF  ADULT  TEETH.        157 

used  gutta-percha  instead  of  gold  for  the  filHng, 
whether  it  was  a  front  or  a  back  tooth,  and  the 
patient  has  generally  been  glad  enough  to  be  so 
mercifully  treated.  I  can  point  to  cases  where, 
side  by  side,  some  such  cavities  are  filled  with  gold 
and  some  with  gutta-percha — the  worst,  of  course, 
being  treated  with  the  latter  material — and  both  I 
and  the  patient  must  live  some  more  years  before  I 
can  say  which  lasts  the  longer. 

In  filling  these  cavities  it  is  a  very  good  pre- 
caution to  pack  against  the  cervical  wall,  leaving  a 
good  mass  of  gold  there  to  be  condensed  after  the 
rest  of  the  cavity  is  quite  full.  This  will  serve  as  a 
breakwater,  and  the  completion  of  the  packing  at  the 
point,  where  there  is  the  greatest  risk  of  wounding 
the  gum,  makes  this  risk  of  less  importance,  since 
the  flooding  with  blood  cannot  be  so  serious  a 
matter  when  the  packing  is  practically  finished. 
But  there  is  really  very  little  danger  of  even  this,  if 
the  packing  is  done  with  a  firm  steady  hand,  the 
third  and  fourth  fingers  resting  on  the  edges  of  the 
tooth,  if  the  operation  is  on  an  upper  tooth,  and  on 
the  chin  if  it  is  on  one  in  the  lower  jaw,  to  prevent 
a  slip,  while  the  second  finger  guides  the  instru- 
ment, held  between  the  thumb  and  first  finger. 
This  resting  of  the  fingers  to  guard  against  slipping 
soon  becomes  purely  instinctive,  though  doubtless 
it  seems  to  the  student  as  if  he  should  always  have 
a  distinct  thought  for  every  thumb  and  finger; 
but  it  is  like  a  practised  performer  on  a  musical 
instrument  whose  fingers  find  the  note  correspond- 


158  DENTAL    PRACTICE. 

ing  to  the  melody  in  the  mind,  without  conscious 
effort. 

The  effect  of  acidity  in  the  mucous  secretion  is 
not  always  confined  to  exposed  dentine,  or  to  cracked 
and  abraded,  or  imperfectly  calcified  enamel.  You 
may  find  the  whole  labial  surface  of  the  incisors 
and  canines  wasting  away,  but  so  generally  and 
uniformly  that,  if  it  were  ground  away  with  car- 
undum  wheels,  and  the  surfaces  carefully  polished, 
the  result  could  not  be  a  smoother  surface.  One  of 
the  most  remarkable  features  of  this  peculiar  form 
of  erosion  is  that,  while  the  destructive  process  is 
going  on,  the  enamel,  and  then  the  dentine  of  one 
portion  or  surface  of  the  tooth  may  be  affected  to 
a  serious  degree,  and  other  adjoining  surfaces  be 
absolutely  untouched.  We  may  find  the  dentine  of 
the  labial  surface  of  a  central  incisor  laid  bare,  and 
the  full  thickness  of  the  enamel  of  the  mesial  and 
distal  surfaces  of  the  same  tooth,  with  the  lingual 
surface,  remain  unaffected,  the  edges  of  enamel 
being  as  sharply  defined  as  though  the  work  had 
been  done  with  a  file.     It  may  attack  the  tooth  in 


Figure  76. — Showing  central  incisors,   with  '^the   labial  surface  partially 
destroyed  by  erosion. 

irregular  patches,  as  shown  in  Fig.  76 ;  or  it  may 
round  off  the  cutting  edge  of  the  incisors,  gradually 


TREATMENT  OF  ADULT  TEETH.        159 

working  its  way  up  to  the  margin  of  the  gum,  until 
more  than  half  the  crown  of  the  tooth  is  cut  away, 
as  shown  in  Fig.  77,  a  case   I  have  watched  for 


Figure  77.— Showing  a  peculiar  case  of  erosion,  in  which  the  whole  of  the 
labial  surface  of  the  two  central  incisors  has  been  destruyed. 

years.  The  sensitiveness  of  the  teeth  to  thermal 
changes  has  been  at  times  almost  unbearable,  but 
alternating  with  periods  of  perfectly  normal  sensi- 
bility. The  articulation  in  this  case  being  faulty 
from  the  first,  the  incisors  of  the  upper  and  lower 
jaw  never  did  meet,  so  that  this  has  not  been  a  case 
of  abrasion,  such  as  might  occur  in  what  is  called 
an  "  underhung  "  mouth,  where  the  lower  incisors 
shut  outside  the  upper,  and  so  gradually  cut  away 
the  labial  surface  of  the  teeth.  Nor  has  it  been  the 
action  of  the  brush,  for,  although  the  teeth  have  been 
well  taken  care  of,  the  attention  of  the  patient  was 
early  enough  called  to  the  wasting  of  the  central 
incisors  to  prevent  any  harsh  treatment.  The 
enamel  on  the  mesial  and  distal  surfaces  and  on 
the  lingual  surface  is  of  normal  thickness,  with 
sharp,  clean  cut  edges,  and  the  pulp  cavities,  pro- 


160 


DENTAL    PRACTICE. 


tected    by    the    formation    of    secondary    dentine, 
distinctly  marked.     The  patient  never  would  con- 
sent to  have  the  crowns  replaced  by  pivoting,  and 
I  never  advised  her  to  have  the  ends 
of  the  teeth  restored  by  building 
them  down  with  gold,  for  I  would 
not  have  had  it  done  in  my  own 
mouth.    So  I  have  recently  extracted 
them,  and  Fig,  78  shows  how  much 
of  the  crowns  had  disappeared. 

I  have  recently  seen  a  delicate 
boy  of  nine  years  of  age,  whose 
incisors  were  apparently  well  covered 
with  enamel  when  they  first  came 
through  the  gum  three  years  ago, 
but  now  it  has  entirely  disappeared 
from  the  labial  surfaces  of  the  lower 
incisors,  and  is  very  thin  on  the 
upper  ones.  The  lingual  surfaces 
also  seem  to  be  much  affected,  while 
the  mesial  and  distal  surfaces  of  all 
the  incisors  are  protected  by  enamel  of  normal  thick- 
ness, the  different  structures  being  clearly  seen  by 
any  ordinary  observer  looking  at  the  child's  mouth. 
The  six-year  molars  in  this  mouth  have  high  cusps 
and  deep  sulci,  but  there  are  no  fissures,  nor 
cavities  requiring  treatment.  I  know  no  way  of 
accounting  for  this  eccentricity  of  action  of  the  oral 
secretions,  nor  has  any  author,  so  far  as  I  know, 
given  anything  like  a  satisfactory  explanation  of  it. 

We    constantly    hear    the     statement    that    a 


Figure  78. — Showing 
the  two  central  in- 
cisors after  extrac- 
tion, {a) — the  labial 
surface  of  the  right 
central,  with  enamel 
destroyed  to  the  mar- 
gin of  the  gum.  (6) — 
the  lingual  surface  of 
the  left  central,  show- 
ing that,  except  as  it 
was  destroyed  from 
the  labial  surface,  the 
enamel  was  unaffect- 
ed ;  this  being  the 
case  with  the  lingual 
surfaces  of  both 
teeth. 


TREATMENT  OF  ADULT  TEETH.        161 

patient's  teeth  were  strong  and  sound  until,  in  some 
illness,  the  doctor  administered  a  very  strong  medi- 
cine, which  quite  ruined  them.  Doubtless  medical 
men  are  themselves  to  blame  for  the  strong  hold 
this  idea  of  the  action  of  medicine  has  upon  the 
public  mind,  for  until  quite  recently  they  have 
failed  to  see  that  it  was  the  illness,  and  not  the 
treatment,  which  was  doing  all  the  mischief  to  these 
organs  ;  and  they  have  practically  admitted  their 
liability  by  advising  their  patients  to  take  tonics, 
and  all  acid  medicines,  through  a  tube,  so  that  the 
teeth  might  not  be  injured. 

A  writer  in  the  New  Yorh  Medical  Record, — I  am 
sorry  that  I  cannot  give  the  name,  but  I  copy  from 
an  abstract  of  the  paper,  and  the  writer's  name  is 
not  given, — says,  "  In  any  febrile  condition,  the 
fluids  of  the  mouth  are  as  constantly  and  intensely 
acid  as  any  medicine  that  is  administered  by  the 
physician  ;  and  from  the  high  temperature  at  these 
times,  the  power  of  these  acids  for  evil  is  greatly 
augmented.  The  consequence  of  this  is  a  rapid 
decomposition  of  food,  etc.,  and  the  elimination  of 
other  deleterious  acids,  all  forming  a  mighty  power, 
under  which  it  is  not  surprising  that  tooth  structure 
should  melt  away  like  dew  before  the  sun.  It  is 
more  surprising  that  any  tooth  should  be  left  to  tell 
the  tale." 

About  two  years  ago  a  young  lady  came  to  me 
after  a  severe  illness,  with  her  teeth,  as  she  and  all 
her  friends  thought,  absolutely  ruined.  Her  teeth 
had  been  regular,  well  shaped,  and  of  good  colour, 

L 


162  DENTAL    PRACTICE. 

and  she  had  doubtless  been  prond  of  them,   and 
justly  so.     They  were  then  very  much  discoloured, 
indeed  almost  black;  the  surfaces  were  rough  and 
uncomfortable  to  the  touch,  and  they  had  been  so 
sensitive  that  she  could  not  bear  to  brush  them ; 
but  in  this  respect  there  had  already  been  a  slight 
improvement   before   she   came  to  consult  me.     I 
made  a  careful  examination  of  the  mouth,  and  found 
really  very  little  deep-seated  mischief,   but  every- 
where the  teeth  were  superficially  affected  by  the 
acid  bath  to  which   they  had   been   subjected  for 
weeks.     The  surfaces  were  rough  and  friable,  but  I 
found  I  could  easily  remove  all  this,  and  by  scraping, 
filing,  and   polishing,  the  appearance  of  the  teeth 
was  restored  to  very  nearly  what  it  had  been  before 
the  illness.      The  frequent  use  of  carbolic   acid — 
a  drachm  of  the  acid  to  a  pint  of  water — as  a  wash 
and  gargle,  relieved  all  the  sensibility,  so  that  now 
it  would  be  difficult  to  find  a  trace  of  the  mischief 
which  then  seemed  so  serious.     In  this  case  all  the 
surfaces  of  the  teeth  were  affected  alike ;  but  the 
patient  was  young,  and  the  gums  everywhere  covered 
the  necks  of  the  teeth  up  to  the  terminal  edge  of 
the  enamel,  or  else  there  would  probably  have  been 
serious  decay  at  some  points,  and  the  labour  neces- 
sary to  put  the  teeth  in  order  might   have   been 
increased  to  an  almost  indefinite  extent.    In  many  a 
case  no  worse  than  this — I  am  sure,  the  teeth  have 
been  pronounced  hopeless  by  careless  observers,  and 
the   want   of    a   few   encouraging   words   from    an 
experienced     practitioner    would    very    soon    have- 


TREATMENT  OF  ADULT  TEETH.        163 

justified  the  opinion ;  jet  I  do  not  think  that  I  have 
spent  three  hours  altogether  on  this  mouth  since 
the  illness  three  years  ago,  and  only  one  tooth  has 
been  lost,  and  that  a  wisdom  tooth  out  of  position 
for  want  of  room. 

Another  form  of  erosion  affects  only  the  cutting 
edges  of  the  front  teeth,  this  portion  of  the  teeth 
being  acted  upon  to  such  an  extent  that  the  upper 
and  lower  front  teeth  will  not  meet.  In  one  case 
that  came  under  my  observation,  there  was  more 
than  three-sixteenths  of  an  inch  of  space  between 
the  upper  and  lower  central  incisors  when  the  back 
teeth  were  firmly  closed.  In  this  case,  judging  from 
the  appearance  of  the  six-year  molars,  and  from  the 
description  given  by  the  patient,  I  have  no  doubt  that 
the  ends  of  the  teeth  were  of  the  imperfectly  formed 
character  shown  in  Fig.  19 ;  but  the  whole  of  the 
imperfect  portion  of  the  teeth  and,  apparently,  some 
of  the  well-developed  part,  had  disappeared.  It 
could  not  have  been  the  result  of  attrition,  because 
several  years  had  elapsed  since  the  lady  had  been 
able  to  bite  anything  with  the  front  teeth,  and  she 
told  me  that  the  loss  of  substance  had  been  gradual, 
but,  as  far  as  she  knew,  uninterrupted.  To  the 
ordinary  observer  the  teeth  had  the  appearance  of 
being  truncated  as  squarely  as  though  they  had  been 
cut  away  with  a  file,  but  in  reality  the  ends  of  all  the 
teeth  were  slightly  concave,  showing  that  the  den- 
tine had  been  affected  more  rapidly  than  the  enamel. 
The  greatest  loss  of  substance  was  from  the  central 
incisors,   the  least  from  the  canines,  the  bicuspids 


164  DENTAL   PRACTICE. 

being  quite  normal  in  appearance.  I  should  have 
been  glad  to  have  seen  more  of  this  case,  but  the 
lady  was  not  in  a  position  to  afford  any  expensive 
treatment,  and  I  simply  advised  her  to  dry  the  ends 
of  the  teeth  every  night,  and  touch  them  with  strong 
carbolic  acid.  There  can  be  no  doubt  that  gold 
fillings  on  the  ends  of  all  these  teeth  would  have 
absolutely  stopped  the  progress  of  the  disease,  and 
there  need  not  have  been  an  attempt  to  restore  the 
natural  length  of  the  tooth  with  gold,  which  would 
have  simply  made  the  mouth  abominably  con- 
spicuous and  unsightly.  But  if  operator  and  patient 
had  agreed  that  it  was  desirable  to  build  the  teeth 
up,  or  down,  as  the  case  might  be,  to  their  natural 
length,  it  would  merely  be  necessary  to  keep  the 
mouth  dry  a  little  longer  to  do  it.  A  shallow  cavity, 
very  slightly  undercut,  should  be  formed  in  the  end  ■ 
of  each  tooth,  and  when  the  anchorage  of  the  filling 
is  properly  made,  it  is  merely  a  question  of  keeping 
the  cavity  dry,  whether  the  filling  shall  be  a  six- 
teenth of  an  inch,  or  an  inch  in  thickness.  But  to 
my  mind  it  seems  quite  enough  to  stop  the  progress 
of  the  disease,  without  attempting  to  make  a  show 
of  gold,  which  would  make  the  patient  even  more 
remarkable  than  "  Miss  Kilmansegg  with  her  golden 
leg,"  which  was  probably  not  displayed  to  the 
admiring  gaze  of  every  person  she  might  speak  to, 
or  greet  with  a  smile  of  recognition.  In  all  these 
cases  of  erosion  the  teeth  affected  by  it  are  usually 
exquisitely  sensitive  to  changes  of  temperature 
or  to  touch,  even  of   the   tooth-brush,    while   the 


TREATMENT  OF  ADULT  TEETH.        165 

disease  is  in  active  progress,  and  at  such  times  the 
apphcatiou  of  the  strongest  Hquid  form  of  carbolic 
acid  will  give  relief,  and  undoubtedlj^  has  the  effect 
of  checking  the  disease.  A  camel's  hair  brush  may 
be  used  for  the  application.  The  surface  on  which 
the  acid  is  to  be  used  should  first  be  dried  with  a 
towel,  so  that  it  will  not  flow  beyond  where  its  action 
is  desired.  This  treatment,  however,  must  not  be 
entrusted  to  careless  or  unskilful  hands.  The  fre- 
quent use  of  carbolic  acid,  in  weak  solution,  as  a 
wash  for  the  mouth,  to  cleanse  the  mucous  mem- 
brane and  neutralize  the  acid  secretions,  will  also  be 
found  advantageous. 

If  the  disease  has  made  sufficient  progress  to 
expose  the  nerve,  as  it  may  do,  it  will  be  a  difficult 
matter  to  treat  it  with  arsenical  dressings  to 
devitalize  the  pulp  without  using  a  drill,  for  the 
dressing  cannot  be  kept  in  contact  with  the  smooth 
surface  of  the  tooth.  x\ny  point  may  be  selected, 
where  easy  access  to  the  pulp  can  be  obtained  by 
the  use  of  a  drill,  and  the  dressing  may  be  kept  in 
position  until  sloughing  of  the  nerve  takes  place, 
when  it  may  be  removed  without  any  pain,  and  the 
pulp  cavity  and  the  drill  hole  may  then  be  filled. 
But  in  these  cases  of  erosion,  the  progress  is 
generally  slow  enough  for  the  nerve  to  protect 
itself  from  exposure,  and  it  is  wonderful  to  see  how 
this  is  accomplished.  The  nerve  retreats  before  the 
advancing  enemy,  and  throws  out  a  new  formation 
of  dentine,  commonly  called  secondary  dentine,  to 
cover  its  retreat.    This  formation  is  quite  translucent 


166  DENTAL    PRACTICE. 

in  appearance,  and  distinctly  more  dense  in  struc- 
ture than  ordinary  dentine,  although  Mr.  Tomes 
says  its  "  tubular  and  intertubular  structure  is  con- 
tinuous with  that  of  the  older  tissue."  It  will  some- 
times fill  up  the  whole  of  the  coronal  portion  of  the 
pulp  cavity  with  solid  substance ;  but  it  is  not 
always  so  beneficial  to  the  health  of  the  tooth  as 
when  it  thus  effectually  protects  the  pulp  from 
exposure  by  the  slow  advance  of  erosion  or  decay  ; 
for  it  may  be  the  obscure  cause  of  a  great  deal  of 
suffering  when  it  takes  the  form  of  what  are  called 
nodules  in  the  pulp.  These  pulp  stones,  as  they 
are  also  sometimes  called,  are  probably  always  con- 
nected with  some  of  the  dentinal  tubes,  as  there  is 
no  reason  to  suppose  that  they  are  spontaneously 
and  independently  formed  in  the  substance  of  the 
pulp,  except  that  they  are  usually  found  detached. 
This,  however,  would  be  accounted  for  by  any,  even 
the  slightest,  disturbance  of  the  pulp  in  searching 
for  them,  as  the  connection  with  the  walls  of  the 
pulp  cavity  may  be  by  the  smallest  number  of  these 
tubes.  It  surely  is  reasonable  to  suppose  that  they 
have  a  starting-point,  and  no  foreign  substance  is 
likely  to  reach  the  pulp,  through  the  dense  struc- 
ture of  the  tooth,  to  form  a  nucleus.  But  however 
this  may  be,  their  formation  in  the  pulp  causes 
in  the  nerve  tissue  great  irritation,  which  is  difficult 
to  localize,  and  may  therefore  be  referred  to  some 
totally  different  cause.  Perhaps  the  tooth  may  not 
even  be  thought  of  in  searching  for  a  cause  of  pain, 
which  may  have  its  origin  in  these  nodules.     Their 


TREATMENT  OF  ADULT  TEETH.        167 

presence  may,  however,  be  suspected,  if,  during  the 
paroxysms,  percussion  on  the  teeth  of  the  affected 
side  has  any  perceptible  effect,  either  to  intensify 
or  to  mitigate  the  pain,  or  a  jet  of  cold  water  from  a 
dentist's  syringe  may  be  employed  upon  the  teeth, 
one  after  another,  to  see  if  any  effect  is  produced 
upon  the  pain.  The  proper  treatment,  when  there 
is  good  reason  to  suspect  this  formation  to  be  a 
source  of  pain,  is  to  drill  into  the  tooth  in  such  a 
position  as  to  give  straight  and  direct  access  to  the 
root  or  roots;  devitalize,  and  then  remove  the  nerve 
and  fill  the  canals  and  pulp  cavity. 

When  a  number  of  the  back  teeth  have  been 
lost,  so  that  the  mastication  of  the  food  is  thrown 
upon  the  anterior  teeth,  they  will  be  rapidly 
worn  down,  and  will  then  present  a  truncated 
appearance  very  similar  to  that  resulting  from  the 
last-mentioned  form  of  erosion ;  but  as  it  will  be 
from  a  very  different  cause,  and  one  easily  under- 
stood, it  does  not  form  so  interesting  a  subject 
for  theoretical  study.  The  concavity  at  the  end 
of  the  tooth  will  generally  be  more  marked  than 
when  it  is  the  result  of  erosion  only.  The  dentine 
is  worn  away  more  rapidly  than  the  enamel,  and 
the  enamel  proves  itself  to  be  better  capable  of 
resisting  the  action  of  attrition  than  that  of  the 
subtle  acids  contained  in  the  oral  fluids.  When  the 
teeth  are  being  worn  down  in  this  way,  it  is  if 
possible,  even  more  necessary  to  protect  their  ends 
with  well-condensed  gold  fillings,  than  when  the 
loss  of  substance  is  from  erosiou,  and  the  occlusion 


168  DENTAL    PRACTICE. 

of  the  teeth  is  no  longer  a  possibihty.  The  form 
the  fining  is  to  take  is  also  a  matter  of  much 
greater  importance  in  cases  of  this  nature,  for  it 
becomes  necessary  to  consider  how  much  thickness 
will  be  most  useful,  and  how  little  will  be  possible 
to  save  unsightliness,  and  preserve  strength  and 
safety  from  breakage.  These  considerations  are 
most  important,  for  if  a  filling  on  the  end  of  a  tooth 
is  too  thin  for  its  superficial  extent,  it  may  be 
broken,  as  I  have  found  sometimes,  when  I  fully 
believed  I  had  made  a  filling  that  had  all  the 
homogeneity  of  rolled  metal.  On  the  other  hand,  it 
must  be  borne  in  mind  that  to  whatever  extent  we 
lengthen  a  tooth,  all  the  rest  will  have  to  be  built 
up  to  the  same  point,  and  shaped  so  as  to  give  an 
equally  good  biting  surface,  for  it  is  absolutely 
necessary  to  preserve  uniformity  of  occlusion.  As 
the  teeth  of  both  jaws  are  equally  liable  to  this  form 
of  abrasion,  it  may  be  necessary  to  protect  the  end 
of  every  tooth  that  has  an  antagonist. 


169 


CHAPTER  VI. 


Amalgam. 

There  is  no  other  subject  connected  with  the 
practice  of  dentistry  that  has  been  the  cause  of 
so  much  heated  controversy  as  the  use  of  amalgam 
for  filling  teeth.  Other  plastic  materials  of  various 
kinds  have  been  used  by  the  skilful,  as  well  as  by 
the  ignorant  and  dishonest  practitioner,  and  when 
the  work  has  failed,  the  failure  has  alike  been 
attributed  to  the  material,  rather  than  to  unskilful 
manipulation  ;  but  no  other  material  has  ever  been 
accused  of  a  tithe  of  the  faults  imputed  to  amalgam. 
At  the  time  of  the  establishment  of  the  earlier 
dental  schools  in  America,  the  students  were 
instructed,  that  not  only  were  the  teeth  in  which 
amalgam  was  used  absolutely  ruined,  but  that 
grave  constitutional  effects,  such  as  salivation, 
necrosis  and  pyaemia,  might  be  expected  to 
result  from  its  presence  in  the  mouth.  Some 
of  our  best  men  felt  themselves  bound  to  dis- 
pute the  claim  of  all  or  any,  who  experimented 
with  amalgam,  to  professional  standing  or  recog- 
nition, and  lost  no  opportunity  of  coupling 
the  epithets  "charlatan"  and  "quack"  with  the 
names  of  the  ostracized  few,  who  dared  to  think 


170  DENTAL    PRACTICE. 

that  this  metallic  mixture  was  not  quite  so  injurious 
as  the  profession  was  taught  to  consider  it.  Yet, 
prejudiced  as  these  men  were,  they  were  much  too 
conscientious  to  go  on  for  ever  condemning  on  mere 
hearsay  evidence.  Now  and  then  they  saw  a  tooth 
that  had  been  filled  with  amalgam,  and  the  patient 
had  survived  the  operation  and  its  consequences. 
There  was  no  appearance  of  necrosis  or  ptyalism. 
Even  the  tooth,  though  rather  discoloured,  did  not 
appear  to  have  decayed  any  more  rapidly  for  having 
the  filling  in  it.  Indeed,  if  it  were  not  contrary  to 
all  preconceived  ideas,  they  might  think  that  the 
filling  had  saved  the  tooth  and,  if  the  patient  was 
inclined  to  take  the  risk  of,  possibly,  serious  conse- 
quences, they  were  not  unwilling  to  leave  this 
dangerous  compound  in  the  tooth,  and  see  how  it 
went  on.  Fortunately,  some  of  the  patients  were 
not  afraid  ;  so  the  sceptics,  finding  that  the  looked- 
for  ill-results  failed  to  appear,  were  inclined  to  try 
an  amalgam  filling  themselves  on  some  safe  patient, 
whom  they  could  trust  to  keep  the  secret.  Thus  in 
time,  but  very  slowly,  the  prejudice  wore  away,  the 
usefulness  of  this  material  came  to  be  recognised, 
and  now  there  are  not  many  men  in  the  profession 
who  do  not  give  it  a  place  in  their  list  of  materials 
for  fillings. 

I  cannot  claim  for  myself  that  I  was  unafiected 
by  this  prejudice.  On  the  contrary,  I  wrote  twenty 
years  ago  as  decidedly  against  the  use  of  amalgam 
as  any  of  my  contemporaries,  and,  as  was  the  case 
with  others,  it  was  only  when  I  began  to  see  that  I 


AMALGAM.  171 

had  no  real  evidence  of  any  deleterious  effect  from 
it,  that  I  began  to  try  it,  in  what  I  then  considered, 
to  be  hopeless  cases  for  anything  more  than  mere 
temporary  work.  The  result  convinced  me  that 
teeth  could  be  saved  with  amalgam  fillings,  espe- 
cially in  grinding  surface  cavities,  but  I  found  that 
in  approximal  cavities,  in  back  teeth,  where  I  had 
hoped  for  good  results,  a  certain  proportion  of 
fillings  failed  at  the  cervical  edge.  Whether  it  was  a 
larger  proportion  than  when  the  fillings  were  of 
gold,  I  had  no  statistics  to  tell ;  but,  though  the 
difference  could  not  have  been  great,  it  was  pro- 
bably against  the  amalgam,  because  it  was  used  in 
cavities  which  I  should  have  filled  with  tin  rather 
than  gold.  I  was  using  gutta-percha  also  at  this 
time,  and  seeing  that  fillings  of  this  material  never 
failed  at  the  cervical  edge,  but  were  only  affected  by 
attrition,  it  occurred  to  me  to  try  the  effect  of  com- 
posite fillings.  The  points  most  liable  to  failure 
from  decay  were  first  carefully  packed  with  gutta- 
percha, and  the  remainder  of  the  filling  made  up 
with  amalgam.  A  filling  of  this  nature  made  it 
essential  that  the  patient  should  pay  a  second  visit 
to  have  the  whole  approximal  surface  finished  down 
smoothly,  as  it  was  often  necessary,  in  or(^er  to 
secure  perfect  dryness  while  pacldng  the  filling,  that 
the  gutta-percha  should  project,  and  overlap  and 
press  away  the  gum,  which,  by  stopping  the  circula- 
tion for  the  time,  would  prevent  flooding  of  the 
work.  This,  of  course,  could  not  be  cut  away  until 
the    amalgam    was    so  hard  that   it   would  not   be 


172  DENTAL    PRACTICE. 

disturbed  by  the  instrument  used  for  trimming  the 
gutta-percha.  The  second  visit  made  the  work 
more  satisfactory  in  another  respect,  because  while 
amalgam  can  only  be  made  smooth  when  it  is  just 
packed,  it  will  take  a  very  fine  polish  after  it  gets 
hard,  and,  if  made  of  good  materials,  will  retain  it. 
This  method  of  filling  large  approximal  cavities 
combines  all  the  advantages  of  two  of  the  most 
useful  materials  we  have  yet  discovered  for  stopping 
teeth,  and,  I  think,  comes  as  near  perfection  as 
anything  we  are  likely  to  find  for  this  class  of 
cavities  in  molars.  It  seems  to  me  a  waste  of  time 
to  attempt  to  build  up  half  or  two-thirds  of  the 
crown  of  a  molar  tooth  with  gold,  when  it  can  be  so 
effectually  done  in  this  way.  Indeed,  it  does  not 
matter  how  much  of  the  crown  of  the  tooth  is 
broken  down  so  long  as  enough  is  left  to  keep  the 
roots  together ;  it  can  be  built  up  so  as  to  make  a 
useful  tooth.  In  a  paper  read  before  the  Odonto- 
logical  Society  of  New  York,  in  December,  1881,  I 
gave  a  full  description  of  a  method  of  building  up 
these  molar  crowns  with  the  help  of  a  thin  gold 
band  to  act  as  a  matrix  and  give  form  to  the  crown, 
the  band  being  attached  to  wires  fixed  in  the  roots 
of  the  tooth  I  will  quote  this  description  from  the 
report  given  in  the  Dental  Cosmos.  Screws  might 
be  used  with  advantage  to  secure  the  frame  to  the 
roots,  and  it  does  not  matter  how  rough  the  interior 
of  the  frame-work  may  be,  as  the  roughness  will 
assist  in  retaining  the  filling  : — 

"With  gutta-percha  and  amalgam  we  may  often 


AMALGAM.  173 

build  up  a  useful  crown  upon  the  otherwise  useless 
roots  of  a  broken  down  molar,  which  it  might  take 
hours  of  hard  labour  to  build  up  with  gold.     I  will 
endeavour,  as  concisely  as  possible,  to  explain  my 
method  of  doing  this.     Supposing  the  roots  to  be 
in  a  healthy  condition,  we  will  insert  short  pieces  of 
wire,  loosely,  in  the  pulp  canals,  with  the  ends  pro- 
jecting; then  take  a  good  impression  of  the  root, 
the   wires   coming   away  with   the   impression ;    if 
there   are   fragments   of  the   crown   remaining   so 
much  the  better,  as  they  will  be  serviceable.     When 
the  plaster  cast  is  made,  we  ought  to  be  able  to  see 
the  exact  position,  and  judge  of  the  direction  of  the 
canals,  and  into  each  of  them  we  drill  a  small  hole 
about  a  tenth   of  an   inch  deep,   the   holes  being 
naturally  a  little  divergent.     We  will  now  make  a 
ring  of  thin  gold  plate,  shaping  it,  if  one  likes  to 
take  the  trouble,  to  the  form  of  the  tooth  we  are 
replacing,  but  fitting  it  outside  any  remaining  frag- 
ments of  the  crown  ;  then  to  the  inside  of  this  ring 
we  solder  two  strips  of  gold  plate,  with  the  ends 
bent  at  such  an  angle  and  of  such  length  that  they 
will  cover  the  holes  in  the   roots ;   drill  these  at 
points  corresponding  to  the  holes,  and  insert  pins 
in  the  right  direction,  so  that  when  sprung  into 
place  they  will  hold  the  ring  in  position.     It  is  best 
also  to  solder  two  or  three  short  studs  to  the  inside 
of  the  ring  to  assist  in  retaining  the  filling.     We 
will  now  make  such  retaining  points  as  we  can  in 
the  natural  root.     Spring  the  ring  into  its   place, 
with  the  pins  in  the  divergent  canals,  adjust  the 


174  DENTAL    PEACTICE. 

articulation,  and  then  pack  gutta-percha  over  the 
whole  surface  of  the  root,  half  filling  the  ring  with 
that  preparation,  and  finishing  with  amalgam.  I 
have  made  some  very  serviceable  teeth  in  this  way  ; 
and,  as  will  be  seen,  nearly  all  the  work  is  done  in 
the  laboratory,  saving  both  patient  and  operator  a 
great  deal  of  time  and  trouble." 

As  we  never  have  two  precisely  similar  cases,  it 
will  be  necessary  to  modify  the  treatment  to  suit 
each  particular  case,  but  adaptation  is  easy,  when 
once  the  idea  is  suggested. 

Nearly  all  molar  cavities  are  suitable  for  amal- 
gam, but  it  is  sometimes  desirable  and  politic  to 
make  exceptions,  such  as  small  or  medium-sized 
cavities,  in  first  upper  molars,  and  small  cavities  in 
the  buccal  sulcus,  all  of  which  may  be  filled  with 
gold,  if  the  operator  feels  inchned  to  take  a  little 
more  trouble  for  the  sake  of  appearance.  This  is  a 
consideration  that  should  not  be  lost  sight  of, 
although  it  ought  not  to  be  a  ruling  motive  of 
practice.  Cervical  buccal  cavities  in  molars  will  do 
better  with  gutta-percha  than  with  anything  else. 

I  have  never  yet  seen  an  amalgam  that  I  felt 
justified  in  using  in  front  teeth,  as  at  the  best  there 
is  a  certain  amount  of  discolouration,  which  cannot 
be  avoided.  It  is,  I  think,  better  to  trust  to  gutta- 
percha, as  long  as  a  plastic  filling  is  necessary,  and 
then  fill  with  gold,  rather  than  to  try  to  make  a 
composite  filling,  which,  from  the  form  of  the 
cavities  in  front  teeth,  is  a  very  difficult  thing  to  do 
so  as  to  prevent  the  metallic  portion  of  the  filling 


AMALGAM.  175 

from  showing  through  the  labial  wall  of  the  tooth, 
and  yet  make  it  secure. 

Here  I  cannot  refrain  from  alluding  to  one  of 
the  difficulties  which  the  dentist  has  to  encounter  in 
his  practice,  and  that  is,  that  all  the  materials  for 
filling  teeth,  except  gold  foil,  are  liable  to  deteriora- 
tion in  the  manufacture,  as  soon  as  a  demand  for 
them  is  secured.  It  is  not  very  creditable  to  those 
who  prepare  materials  for  the  dentist  to  use  in 
plastic  fillings,  that  so  many  of  the  preparations  fail 
to  keep  up  the  character  in  which  they  are  first 
presented  to  the  profession,  after  they  have  become 
sufiiciently  well  known  to  create  a  brisk  demand  for 
them.  Of  course  this  is  because  the  early  experi- 
ments were  made  by  some  one  person,  who  takes 
care  that  everything  he  uses  shall  be  of  the  best 
quality ;  the  ingredients  are  accurately  weighed,  and 
his  manipulation  is  as  nearly  as  possible  perfect. 
But  when  quantities  are  required,  he  must  have 
assistance  in  the  work,  and  then  materials  are  not 
selected  with  so  much  care,  and  the  exact  propor- 
tions are  not  maintained.  It  ought  to  be  possible 
for  the  dentist  to  trust  his  manufacturer  as  the 
physician  does  his  chemist ;  and  I  hope  this  hint 
will  be  one  step  towards  a  better  state  of  things. 

Many  preparations  of  alloys  for  amalgam  have 
been  tried,  but  I  confess  I  have  never  had  much 
experience  with  any  one  that  took  a  descriptive  name 
from  any  of  the  precious  metals.  If  a  dentist  does 
his  duty  to  his  patient,  he  takes  care  to  select,  for 
filling  teeth,  the  material  that  he  thinks  best  suited 


176  DENTAL    PRACTICE. 

to  the  case,  and  if  asked  to  do  so,  frankly  explains 
the  nature  of  his  selection,  and  the  reasons  for 
using  it.  There  is  no  necessity  for  him  to  disguise 
the  fact  that  he  is  using  amalgam,  by  calling  it 
a  gold  or  a  platinum  alloy.  Silver  and  tin  are,  and 
must  be,  the  metals  chiefly  used  in  all  amalgams, 
and,  if  other  metals  are  used,  it  is  only  in  very 
minute  quantities,  which  cannot  affect  the  intrinsic 
value  of  the  alloy  to  any  appreciable  extent,  and  are 
introduced  to  prevent  shrinkage  or  discolouration. 
It  is,  therefore,  a  mere  pretence,  unworthy  of  a  pro- 
fessional man,  to  call  these  fillings  by  any  other 
than  the  accepted  name  in  the  profession. 

The  cavity  must,  of  course,  be  in  every  sense  as 
carefully  excavated  as  it  would  be  for  a  gold  filling. 
There  must  not  be  any  fragile  walls  left  to  break 
down  after  the  filling  is  inserted.  It  is  better  to  cut 
away  all  such  walls  to  a  point  where  their  strength 
can  be  trusted,  and  then,  if  necessary,  this  can  be 
further  protected  by  building  up  the  filling  to  some- 
thing near  the  original  form  of  the  tooth,  covering 
the  edges  of  enamel,  and  so  reducing  the  danger 
of  fracture  to  a  minimum.  Undercutting  to  any 
extent  is  always  a  mistake,  and  leaving  wide  over- 
hanging edges  of  enamel  is  worse  still.  In  the 
latter  case  the  excavation  may  be  faulty,  and  though 
it  is  right  sometimes  to  leave  a  part  of  the  decalci- 
fied dentine  over  the  nerve,  it  can  never  be  right  to 
leave  any  at  the  lateral  edges  of  the  cavity  when 
making  a  permanent  filling.  It  can  never  be  a  cer- 
tainty that  the  filling  material  can  be  packed  into 


AMALGAM.  177 

deep  cuttings,  or  under  wide  overhanging  edges, 
while,  if  it  is  not,  a  weak  point  is  left  in  the  work, 
and  as  the  strength  of  a  cable  depends  upon  its 
weakest  link,  so  the  value  of  a  filling,  as  a  preser- 
vative from  decay,  must  depend  upon  its  weakest 
point. 

It  is  important  in  mixing  an  amalgam  for  use, 
that  the  quantity  of  mercury  should  be  as  small  as 
will  suffice  to  make  a  cohesive  mass  of  the  filling. 
For  this  purpose,  if  for  no  other,  it  is  desirable  that 
the  bottle  containing  the  supply  of  mercury  should 
have  a  very  small  aperture  to  allow  the  mercury  to 
be  added  in  minute  globules,  and  that  the  alloy 
should  be  finely  granulated.  The  mixing  should 
be  done  in  the  palm  of  the  hand,  unless  the  hands 
are  moist  from  perspiration,  when  a  small  mortar  is 
better.  A  thin  ivory  spatula  is  the  only  instrument 
necessary  when  the  hand  can  be  used,  and  I  think 
the  danger  of  mercurial  poisoning  by  using  the 
hand  for  this  purpose  is  a  remote  contingency, 
worthy  to  be  classed  with  the  invasion  of  England 
by  way  of  the  Channel  tunnel. 

In  packing  an  amalgam  small  round  points  are 
by  far  the  best,  and  they  should  be  used  with  a 
gentle  tapping  pressure  to  secure  the  filling  of  every 
minute  irregularity  in  the  form  of  the  cavity,  and 
the  complete  union  of  the  particles.  When  the 
cavity  is  full  and  the  contour  built  up  to  the  desired 
extent,  an  ordinary  burnisher  may  be  used  for 
smoothing  the  surface.  A  bit  of  amadou,  twisted 
up  tightly  and  held  in  the  plugging  pliers,  serves  to 

M 


178  DENTAL    PRACTICE. 

remove  all  loose  particles,  and  then  it  may  be  left 
to  harden,  before  receiving  the  final  polish. 

Dr.  0.  C.  Allen  once  paid  a  deserved  tribute  to 
the  value  of  amalgam  as  a  stopping  for  teeth,  at  a 
time,  too,  when  it  was  not  so  appreciated  as  it  is 
now,  by  saying, — ' '  If  my  life  and  fortune  depended 
upon  the  saving  of  a  tooth  without  regard  to  its 
appearance,  I  would  fill  it  with  amalgam." 

I  make  the  following  extract  from  a  letter  I  have 
received  from  Dr.  Foster  Flagg  since  writing  this 
article.  Knowing  of  his  long  course  of  thoroughly 
practical  experiments  in  the  nature  and  working  of 
various  combinations  of  metals  for  amalgams  to  be 
used  in  filling  teeth,  I  wrote  to  him  for  further 
information  as  to  the  value  of  the  precious  metals 
in  these  alloys. 

"Your  ideas  of  the  'chief  positions  of  silver 
and  tin,  as  components  of  alloys  for  amalgams  for 
filling  teeth,  correspond  with  the  conclusions  I  have 
reached  in  experiments.  I  also  am  '  on  the  record  ' 
in  reference  to  platinum  as  a  valueless  metal,  and 
one  which  is  only  useful  for  its  name !  I,  therefore, 
regard  its  employment  as  fraudulent,  and  its  accep- 
tance as  discreditable  to  the  intelligence  of  the  den- 
tal profession.  .  Gold  and  copper  and  zinc  I  view 
differently.  Each  of  these  metals  shows  proof  of 
its  presence,  by  giving  increased  value  to  amalgams, 
as  shown  by  appropriate  testings.  But  in  the 
so-called  '  gold  and  platinum  '  alloys  there  is 
very  seldom  enough  gold  to  give  any  appreciable 
increased  value  to  the  amalgam,  if  judged  by  its 


AMALGAM.  179 

ivorhing  characteristics.  At  least  five  per  cent,  of 
gold  is  needed,  and  it  is  not  proven  that  much  more 
is  not  beneficial — especially  as  regards  maintenance 
of  colour— though  of  this  I  am,  as  yet,  sceptical. 
The  experiments  of  the  '  New  Departure  Corps ' 
gave  decided  value  to  copper,  also  to  zinc  as  a  pre- 
vention to  shrinkage."  The  letter  closes  with  a  few 
sentences  expressing  his  regret  for  his  inability  to 
write  more  at  present  upon  subjects  which  have 
recently  so  severely  taxed  his  strength,  and  his 
intense  interest  in  the  queries  propounded. 


180 


CHAPTEK  VII. 


Pivoting. 


A  GREAT  deal  has  been  written  in  the  last  few  years 
about  restoring  the  crowns  of  broken  down  teeth  by 
various  processes  of  pivoting,  but  some  of  the 
methods  described  have  been  such  as  to  deter  the 
great  majority  of  operators  from  attempting  them, 
because  of  the  difficulties  that  must  occur  in  the 
manipulation,  and  the  amount  of  labour  involved. 
To  those  who  prefer  to  spend  their  time  over  some 
of  these  laborious  processes,  I  have  not  a  word  to 
say.  They  will  find  their  satisfaction  in  having 
performed  a  very  beautiful  operation,  at  the  cost  of 
hours  of  toil,  with  utter  weariness  at  the  finish,  and 
the  consciousness  that  only  the  professional  training 
of  a  dentist  will  ever  enable  any  one  to  appreciate 
the  work.  But  to  those  who  will  be  satisfied  with 
an  operation  which  will  look  as  well  to  any  ordinary 
observer,  be  as  comfortable  to  the  patient,  and 
certainly  last  as  long  as  any  one  of  the  more  com- 
plicated and  difficult  operations,  I  have  a  few 
suggestions  to  make  for  improvements  on  the  old 
processes,  without  materially  increasing  the  labour, 
and  without  claiming  originality,  except  in  the 
manipulation,  and  perhaps — for  I  do  not  remember 


PIVOTING.  181 

that  I  have  ever  seen  it  suggested,  except  in  a  paper 
of  my  own — the  idea  of  interposing  a  gutta-percha 
filling  between  the  cervical  end  of  the  root  and  the 
artificial  crown,  thus  preventing  decay  at  this  vital 
point  in  all  pivoting  operations. 

We  will  suppose  that  we  are  operating  on  any 
one  of  the  six  upper  front  teeth,  and  that  the  pulp 
is  already  devitalized.  We  first  cut  away  the 
remaining  fragments  of  the  crown,  using  the  engine 
as  much  as  possible  for  this  purpose,  and  the 
excising  forceps  as  little  as  possible,  for  the  jar 
from  the  latter  is  very  irritating  to  the  peridental 
membrane,  which,  perhaps,  is  ripe  for  the  develop- 
ment of  alveolar  abscess  from  very  slight  causes. 
A  thick-edged  corundum  wheel,  and  a  round  or 
oval  file,  will  enable  the  operator  to  shape  the 
end  of  the  root  so  as  to  correspond  to  the 
margin  of  the  gum,  and  be  just  slightly  hidden 
by  it,  so  that  when  the  tooth  is  fixed  in  position 
the  joint  will  be  covered  by  the 
gum.  Fig.  79.  We  then,  with  fine 
hooked  or  barbed  instruments, 
scrape  away  all  putrescent  matter 
from   the   pulp  canal,    taking   care     Figure  79.-showmg 

that   we    do    not     push     any     of  this       the  root  prepared  for 
,     ,  , ,  1,1  taking    the    impres- 

poisonous   substance    through    the     sion. 
apical    foramen,    and    also    taking 
care   to    keep    the    instrument   wet    with    carbolic 
acid,  washing  it  in  the  acid  every  time  we  with- 
draw  it   from   the   root.     We  then,  with   a    small 
drill  that  will  follow  the  canal,  open  and  straighten 


182  DENTAL    PRACTICE. 

the  latter,  lubricating  with  carbolic  acid.  We 
then  use  a  larger  and  still  larger  drill,  until 
the  hole  is  large  enough  to  admit  the  gold  wire 
which  is  prepared  for  the  English  tube  tooth, 
as  this  is  of  a  proper  size,  and  being  already 
straightened,  it  saves  trouble.  The  pulp  canal 
should  all  the  time  be  kept  wet  with  carbolic  acid, 
and  the  wire  should  slip  easily  in  and  out  of  the 
hole,  but  not  too  loosely,  and  the  hole  should  be 
at  least  three-eighths  of  an  inch  in  depth.  The 
purpose  of  the  gradually-increasing  size  of  the 
drill  is  to  enable  us  to  feel  the  way,  and  avoid  per- 
foration of  the  sides  of  the  root.  We  then  flatten 
the  end  of  a  piece  of  the  wire  to  a  chisel  edge,  and 
barb  the  sides  of  the  flattened  portion  thus,  Fig.  80, 
cutting  this  so  that,  when  the  wire  is  in  the  hole, 
the  barbed  end  will  be  a  trifle  shorter  than  the  teeth 
on  either  side,  so  that  in  taking  the  impression  the 
tray  will  not  press  on  the  wire.  We  now  place  the 
wire  in  position  thus,  Fig.  81,  and  take  an  impres- 


Figure  80. — Showing  form  Figure  81. — Showing  wire  in  position  for 

of  wire.  taking  impression. 

sion,  which  shall  bring  the  wire  away  with  it,  with- 
out altering  its  direction  in  the  least ;  the  barbing 
of  the  sides  of  the  wire  being  to  assist  its  with- 
drawal.    The  impression  need  not  cover  more  than 


PIVOTING.  183 

one  tooth  on  either  side  of  the  root  we  are  treating  ; 
and  indeed  is  better  so,  as  the  wire  is  then  more 
readily  withdrawn  without  altering  its  direction. 
When  the  model  is  cast,  all  that  we  want  is  a 
distinct  representation  of  the  root,  with  the  wire  in 
position,  showing  the  exact  direction  of  the  hole  in 
the  root,  and  the  form  of  the  teeth  on  each  side  of 
it.  Before  dismissing  the  patient  from  this  first 
sitting,  we  select  a  flat  tooth  of  suitable  form  and 
colour,  and  take  care  that  the  root  canal  is  open  to 
and  through  the  apical  foramen.  We  dry  the  canal 
with  a  twist  of  bibulous  paper,  and  apply  a  dressing 
of  carbolic  acid,  which  we  cover  with  cotton  and 
gum  sandarac.  If  the  tooth  is  broken  down  below 
the  surface  of  the  gum,  and  the  latter  growing  over 
it,  we  may  so  pack  the  cotton  and  gum  sandarac  as 
to  press  the  gum  away,  and  in  this  case  we  must 
defer  taking  the  impression  until  the  end  of  the 
root  is  uncovered,  and  its  surface  cleaned  and  pro- 
perly shaped.  It  is  important  that  the  wire  should 
be  of  the  right  size  and  length,  because  if  it  is  too 
small  it  tips  in  the  hole,  and  thus  gives  a  false 
direction,  which  only  becomes  apparent  after  the 
tooth  is  fitted  and  soldered,  unless  we  keep  the 
patient  waiting  while  the  laboratory  work  is  being 
done,  and  try  the  tooth  in  before  it  is  soldered, 
which  may  sometimes  be  desirable,  but  it  is  not 
necessary,  if  sufficient  care  is  taken.  If  the  wire  is 
too  short,  or  not  roughened  at  the  sides,  or  if  it  fits 
the  hole  too  tightly,  it  will  not  come  away  with  the 
impression.     The  best  way  is  to   have   a  drill   of 


184  DENTAL    PRACTICE. 

exactly  the  right  size,  and  keep  it  for  this  purpose 
only,  as  the  wire  is  procurable  from  any  dental 
depot  in  Great  Britain,  and  is  always  of  the  same 
size.  If  more  than  one  tooth  is  to  be  fitted  in  this 
way,  an  impression  must  be  taken  for  each  tooth,  as 
the  pulp  canals  would  never  be  so  nearly  parallel 
that  two  or  more  wires  could  be  withdrawn  in  the 
same  impression.  Having  made  the  plaster  cast, 
we  find  the  wire  standing  exactly  as  it  was  in  the 
mouth,  and  with  the  teeth  on  either  side  indicating 
exactly  how  the  new  crown  must  be  placed.  Ee- 
moving  the  wire  from  the  cast,  we  now  bend  and 
shape  a  piece  of  gold  plate  to  fit  the  surface  of  the 
root,  and  drill  a  hole  through  it  to  correspond  exactly 
with  the  hole  in  the  root.  Then  putting  the  wire 
through  it  and  fastening  with  wax,  we  withdraw  wire 
and  plate  together,  and  bed  them  in  a  wet  mixture 
of  plaster  and  sand  to  keep  them  in  position  until 
they  are  soldered.  After  this  we  cut  off  the  wire 
from  the  concave  side  of  the  plate,  and  bevel  the 
edges  of  the  latter.  The  wire  and  plate  should  now 
exactly  fit  the  hole  in  the  root  and  the  surface  of  it. 
We  may  now  proceed  to  put  a  backing  on  the  tooth, 
and  grind  it  to  fit  the  anterior  edge  of  the  root. 
When  this  is  satisfactorily  done,  we  place  the  tooth 
in  position  on  the  model,  fasten  it  with  wax,  and 
withdrawing  all  together,  bed  them  in  wet  plaster 
and  sand  for  soldering.  The  plate  and  backing  of 
the  tooth  should  be  of  eighteen  or  twenty  carat 
gold,  the  finer  the  better,  and  the  solder  should  be 
as  fine  as  it  can  be  to  run.     In  selecting  a  tooth, 


PIVOTING.  185 

colour,  form,  and  suitableness  in  every  respect 
should  be  studied,  in  order  to  avoid  the  very 
un-rtrf-ificial  appearance  that  neglect  of  any  one  of 
these  points  would  give  the  finished  work ;  for  art, 
in  these  cases  at  least,  is  imitation  of  nature,  and 
not  an  attempt  to  improve  upon  it.  The  tooth 
being  soldered  to  the  plate,  we  may  smooth  and 
polish  the  lingual  surface,  thus  completing  the 
laboratory  work,  Fig.  82.  We  are  now  ready  to 
try  the  tooth  in  the  mouth,  and  see  if  it  is 
satisfactory  in  every  respect :  form,  position,  colour, 
if  the  bite  is  right,  and  if  the  tooth  fits  so  that 
the    joint    will    not    show.    Fig.    83.      If   in    all 


Figure  82.— Showing  tooth  ready  Figure   83.— Showing  tooth  in 

for  fixing.  '  position. 

these  points  the  work  is  satisfactory,  it  only 
remains  to  fix  the  tooth  in  the  root.  "We  first 
shape  a  cavity  in  the  cervical  end  of  the  root 
of  sufficient  size  and  depth  to  ensure  perman- 
ence for  a  gutta-percha  filling.  The  twentieth  part 
of  an  inch  is  deep  enough,  and  superficially  it 
should  be  at  least  two-thirds  of  the  surface  of  the 
end  of  the  root.  We  undercut  all  around  with  an 
inverted  cone-shaped  drill  attached  to  the  engine ; 
and  with  a  strong  thick-bladed  knife   we  then  barb 


186  DENTAL    PEACTICE. 

the  wire  on  four  sides,  so  that  it  will  require  pres- 
sure to  push  it  into  the  hole,  and  so  render  with- 
drawal difficult,  if  not  impossible.  If  we  have  made 
the  hole  larger  than  was  necessary,  a  little  fine 
floss  silk  may  be  wound  on  the  wire,  but  this  must 
be  very  smoothly  and  evenly  done.  Then  warming 
the  tooth,  we  place  a  sufiicient  quantity  of  gutta- 
percha around  the  wire,  on  the  convex  side  of  the 
plate,  to  fill  the  cavity  we  have  shaped  in  the  end  of 
the  root,  taking  care  to  have  enough,  as  any  surplus 
will  be  squeezed  out.  Now,  if  the  root  is  clean  and 
free  from  disease,  the  terminal  portion  of  the  canal, 
above  the  enlargement  made  with  the  drill,  may  be 
filled  by  first  packing  a  few  fibres  of  cotton, 
moistened  with  carbolic  acid,  up  to  the  apex — being 
careful  not  to  go  beyond,  but  this  can  be  guarded 
against  by  using  a  point  that  will  not  quite  go 
through  the  foramen — a  few  more  fibres  with  a 
little  sandarac  varnish,  then  more  of  the  same,  until 
this  part  of  the  root  is  filled.  A  little  very  stiff 
sandarac  varnish  is  then  placed  in  the  enlarged 
portion  of  the  canal ;  the  tooth  is  again  warmed  in 
the  flame  of  the  lamp,  this  time  as  hot  as  the 
fingers  can  bear  to  hold  it,  so  as  to  thoroughly 
soften  the  gutta-percha;  and  while  it  is  in  this 
heated  condition  we  push  it  firmly  up  to  its  place, 
using  a  piece  of  wood,  notched  at  the  end;  so  as  to 
guide  the  tooth  while  pressing  it  up — wood  being 
better  than  metal  for  this  purpose,  because  it  does 
not  chip  the  tooth.  The  surplus  of  gutta-percha  is 
now   smoothed  away  with  a  warm  burnisher,   and 


PIVOTING.  187 

the  work  is  complete.  The  whole  time  spent  with 
the  patient  in  the  chair  need  not  exceed  half-an- 
honr ;  and  I  am  perfectly  certain  that,  if  the  work  is 
well  done,  it  will  outlast  any  elahorate  operation  of 
building  up  a  back  or  lingual  surface  of  gold  foil 
that  can  be  made  ;  for  the  gutta-percha  is,  I  repeat, 
a  perfect  preservative  from  decay  in  positions  where 
it  is  not  exposed  to  attrition,  from  which  the  plate 
protects  it ;  while  gold  is  never  a  safe  protection 
when  packed  under  the  gum. 

I  had  a  case  some  years  ago  where  a  tube  had 
been  fixed  in  the  root  of  a  central  incisor,  and  a 
gold  filling  packed  around  it  down  to  the  surface  of 
the  root,  and  then  a  tooth  fitted  with  a  wire  secured 
into  the  tube,  very  beautiful  and  highly-finished 
work,  done  by  a  clever  and  celebrated  man,  but  the 
filling  became  loose  in  a  few  months,  and  as  the 
distance  was  too  great  for  the  lady  to  go  back  to 
her  own  dentist,  she  came  to  me  in  great  trouble 
to  see  if  I  could  do  anything,  however  temporarily, 
for  her,  until  she  could  get  home  to  have  it  properly 
done.  I  could  see  that  the  filling  was  quite  loose  ; 
indeed,  it  came  away  with  the  tube  while  I  was 
examining  it,  and  without  the  application  of  any 
force.  The  filling  was  easily  removed  from  the 
tube ;  but  the  wire,  to  which  the  tooth  was 
attached,  was  firmly  fixed  in  the  tube.  I  therefore 
dried  the  root  carefully,  filled  it  quickly  with  gutta- 
percha, and  while  the  latter  was  still  soft,  warmed 
the  tooth  with  the  tube  still  in  position,  and  pressed 
the  whole   firmly  up  to  its   place,  holding  it  there 


188  DENTAL    PRACTICE. 

until  it  was  cool.  It  looked  all  right,  and  felt  firm 
and  strong,  but  the  lady  went  away  feeling  very 
doubtful  about  my  rough  and  ready  treatment. 
She,  however,  remained  abroad  several  years,  and 
called  on  me  on  her  return,  to  say  that  the  tooth,  as 
I  had  replaced  it,  had  lasted  more  years  than  the 
former  operation  had  lasted  months,  and  she  did 
not  mean  to  have  it  disturbed. 

The  use  of  gum  sandarac  in  solution  for  filling 
roots  is,  I  believe,  an  idea  that  has  not  been 
suggested  to  the  profession,  but  it  is  worth  trying. 
If  well  mingled  with  cotton  fibre,  it  will  make  a 
filling  that  will  keep  a  cavity  clean,  and  protect  it 
from  decay  for  months.  I  recently  removed  a 
dressing  of  this  nature,  that  had  been  two  years  in 
a  tooth,  owing  to  the  sudden  departure,  and  con- 
tinued absence  from  home,  of  a  patient  for  whom 
my  brother  had  been  treating  a  dead  tooth.  To  my 
surprise,  the  surface  of  the  cavity  beneath  the 
dressing  was  as  clean  and  dry  as  it  would  have  been 
with  a  proper  filling  in  it.  I  think  Dr.  Foster 
Flagg  has  mentioned  a  case  where  an  arsenical 
dressing  of  his  remained  covered  up  with  cotton 
and  gum  sandarac  for  an  equal  length  of  time. 
The  formula  is — equal  parts  of  gum  sandarac  and 
gum  benzoin  dissolved  in  spirits  of  wine  to  the 
consistence  of  stiff  varnish . 

Pivoting  lower  teeth  is  rarely  a  necessary  opera- 
tion. I  have  never  tried  it  in  the  case  of  lower 
incisors,  and  I  doubt  whether  there  would  be 
sufficient  thickness  of  root  to  admit  a  strong  pivot ; 


PIVOTING.  189 

but  the   operation   can  be  very   satisfactorily  done 
with  the  lower  canines  and  bicuspids,  and  I  have 
often  pivoted  the  upper  bicuspids  in  the  way  I  have 
described   for   the    incisors    and    canines.      But   it 
sometimes  happens  that  one  cusp  only  of  an  upper 
bicuspid  breaks  down,  and  then,  if  the  remaining 
cusp  is  strong,  I  think  it  worth  while  to  preserve  it, 
and  fit  a  new  cusp  of  porcelain  to  replace  that  which 
is  lost,  and  fill  the  space  intervening  between  the 
natural   and   artificial  cusps  with   amalgam.     The 
process  differs  from  those  cases  where  a  crown  is 
replaced — or   rather  the  labial   cusp,  with   a   gold 
backing,  is  fixed  to  give  the  external  appearance  of 
a   crown — but    only    in    some    points    that   would 
naturally  suggest  themselves  to  the  operator.      If 
the  remaining  cusp  is  strong  enough   to   allow  a 
reasonable  hope  that  it  will  not  break  down  when  it 
is  used  for  mastication,  we  cut  away  the  fragments 
of  the  broken  cusp  down  to  and  a  little  beneath 
the   gum   margin,    open    the   root  in  the   manner 
previously  described — only,  if  it  is  a  first  bicuspid, 
remembering  the  probability  of  a  bifurcation  of  the 
root,  and  the  consequent  increased  risk  of  perfora- 
tion of  its  side,  and  being  content  with  an  enlarge- 
ment of  the  canal  to  the  depth  of  a  quarter  of  an 
inch,  because  the  filling  will  assist  in  retaining  the 
artificial  cusp  in  position.      If  there  is  much  over- 
hanging surface  of  enamel  on  the  remaining  natural 
cusp,  it  may  not  be  best  to  cut  it  all  away,  but  leave 
all  that   is  strong.     If  there   is   danger  that   the 
impression    may  drag   in  removing   it,  fill   up  the 


190 


DENTAL    PRACTICE. 


under-cutting  with  some  soft  and  easily  removable 

preparation  of  gutta-percha,  as  we  should  prepare  a 

model  with  wax,  so  that  it  may  draw  properly  out 

of  the  moulding  sand.      Fig.  84. 

Then,  placing  the  wire  in  position, 

we  take  an  impression,  as  in  the 

previous   case,   and   fit   the   new 

cusp  without  a  plate  to  cover  the    ^^s"""    84.-  showing 

^  _  the  root  and  remaining 

surface   of   the  root,  soldering   the     cusp  ready  for  taking  tlie 

wire  directly  to  the  backing  of  ™P^^^^i«°- 
the  tooth,  or  even  to  the  platinum  pins  in  the 
tooth,  and  leaving  the  whole  as  rough  as  possible, 
Fig.  85.  We  should  take  care  that  the  roughness 
does  not  anywhere  extend  quite  to  the  mesial,  or 
distal,  edge  of  the  tooth,  but  make  it  a  roughness 
that  will  be  grasped  by,  and  assist  in  retaining,  the 
amalgam  filling.     Fig.  86  represents  the  artificial 


Figure  85. — Showing  the  artificial 
cusp  with  wire  attached. 


Figure   86. — Showing  the  cusp  in 
position. 


cusp  fitted  to  its  place.  Having  now  cleaned  and 
shaped  the  natural  cusp  to  do  its  part  in  retaining 
the  filling,  we  barb  the  wire,  and  place  the  gutta- 
percha and  sandarac  as  before,  and  after  the  new 
cusp  is  pressed  up  to  its  place,  we  fill  up  the 
space  between  the  two  cusps  with  amalgam,  taking 
care   first    that    the   surface    of    the   root    is   well 


PIVOTING.  191 

covered  with  the  gutta-percha,  and  when  the  filHng 
has  had  time  to  harden,  smooth  and  poUsh  as  in  the 
case  of  an  ordinary  amalgam  filling,  Fig.  87.  The 
labial,  or  lingual,  cusp  may  be  fitted  in  this  manner, 
and  make  very  serviceable  work.  With  a  first 
bicuspid,  when  the  pulp  canal 
indicates  bifurcation  of  the  root, 
we  must  take  care  to  select  that 
which  seems  the  thicker  and 
stronger  root,  and  then  feel  the 

r.   11  -.1     ,1        1    -n        rri  Fifiure  87.— Showing  the 

way  cai-efully  with  the  drill.  The  ^^^^.^^.^^  completed. 
patient  will  feel  sensation  before 
there  is  actual  perforation  of  the  side  of  the  root, 
and  the  driU  should  be  kept  well  lubricated,  or 
else  the  heating  will  cause  sensation  so  similar  to 
that  of  perforation,  that  both  patient  and  operator 
may  be  deceived.  I  have  had  several  cases  where 
the  natural  cusp  has  broken  down  after  a  time, 
and  the  artificial  one,  with  the  filling,  has  remained 
for  years ;  the  only  thing  done  to  them  being  to 
smooth  off  the  sharp  edges  of  the  filling  where 
the  natural  cusp  had  broken  away  from  it. 


192  DENTAL    PRACTICE. 


CHAPTER  VIII. 


Gutta-Percha  for  Impressions. 

In  taking  impressions  for  the  work  I  have  been 
describing  in  the  last  chapter,  as  well  as  for  many 
other  purposes  where  the  dentist  requires  a  good 
plaster  cast,  it  is  very  desirable  to  have  an  accurate 
representation  of  the  neighbouring  teeth,  as  well  as 
of  the  root ;  and  to  obtain  this  it  is  necessary  to  use 
some  unyielding,  inelastic  material  for  the  impres- 
sion, like  plaster  of  Paris,  which  will  set  firmly 
around  the  teeth,  and  must  be  broken  in  removing  it 
from  the  mouth,  and  then  laboriously  put  together 
again;  or  else  a  material  which  is  sufficiently  elastic 
in  its  nature  to  allow  of  its  being  withdrawn  from 
around  the  necks  of  the  teeth  over  the  larger  part  of 
the  crown,  and  then  quickly  contract  again  to  the 
form  it  had  assumed  before  it  was  withdrawn.  Wax, 
and  all  the  preparations  of  mixed  gums  that  are  used 
for  taking  impressions,  are  inelastic  ;  and  while  they 
give  a  good  representation  of  the  gums,  and  of  short 
teeth  that  are  as  large,  or  larger,  at  the  neck  than  at 
any  other  part,  and  are  especially  useful  in  taking 
impressions  for  regulating  plates,  they  are,  as  is 
well  known,  but  imperfectly  adapted  for  impressions 
in  which,  for  artistic  effect,  or  accurate  fitting,  it  is 


GUTTA-PERCHA    FOR    IMPRESSIONS.  193 

desirable  to  have  a  perfect  representation,  in  plaster, 
of  teeth  which  are  narrow  in  the  neck  and  broad  in 
the  crown. 

Gutta-percha  has  been  practically  given  up  by 
the  profession  as  a  material  for  taking  impressions, 
except  in  the  form  of  preparations  which  are  so 
largely  composed  of  other  substances  that  they  have 
no  claim  to  be  called  gutta-percha,  and  have  few,  or 
none,  of  its  peculiar  properties  left.  But  if  properly 
used,  gutta-percha  in  its  pure  state  comes  nearer  to 
being  a  perfect  material  for  this  purpose  than  any- 
thing else  that  has  been  discovered.  It  is  elastic 
where  elasticity  is  desirable,  and  loses  this  quality 
when  it  would  no  longer  be  advantageous.  It  gives 
quite  as  sharp  an  impression  as  plaster,  and  is  as 
easily  managed  as  wax.  It  has  a  clean  resinous 
taste,  and  it  is  unalterable  in  shape  after  it  is  cooled, 
and  as  long  as  it  can  be  kept  cool  and  wet.  It 
should  be  absolutely  pure,  and  ought  always  to  be 
kept  in  water  to  prevent  oxidation.  If  it  is  hard  and 
dry  when  first  obtained,  it  should  be  put  in  hot 
water,  and  kept  for  at  least  two  hours  just  below  the 
boiling  point ;  and  although  boiling  is  one  of  the 
manufacturer's  processes  in  cleansing  and  purifying 
gutta-percha,  it  should  never  be  allowed  to  remain 
long  in  water  that  is  actually  boiling,  as  it  would 
soon  become  too  sticky  for  use.  After  remaining 
for  some  time  in  hot  water,  it  should  be  thoroughly 
kneaded,  and  it  may  then  be  flattened  out  in  small 
pieces — enough  for  an  ordinary  impression — and 
put  in  cold  water  to  be  kept  until  required  for  use. 

N 


194  DENTAL    PEACTICE. 

The  method  of  preparing  it  for  taking  impressions 
is  to  put  it  in  water  of  about  200°  Fahr.,  and  when 
perfectly  soft  it  should  be  slightly  and  quickly 
kneaded  in  the  fingers,  and  the  surface  dried  on  a 
napkin,  before  it  is  put  in  the  tray  to  go  into  the 
mouth.  Then,  after  dipping  the  tray  and  its  contents 
into  cold  water,  to  cool  and  moisten  the  surface,  it 
may  be  placed  in  the  mouth  with  steady,  firm  pres- 
sure, and  allowed  to  remain  at  least  two  minutes 
before  it  is  removed,  which  should  be  carefully  done 
to  prevent  any  alteration  of  form  in  withdrawing  a 
soft  bulky  mass  through  the  comparatively  narrow 
opening  of  the  lips.  The  impressions  should  always 
be  very  quickly  cooled  in  water,  which,  if  the 
weather  is  warm,  should  be  iced. 

Although  this  is  not  a  work  on  mechanical  den- 
tistry, it  may  not  be  out  of  place,  as  I  am  writing 
of  impressions  with  a  material  that  is  not  in  general 
use,  to  say  that,  in  taking  impressions  of  edentulous 
mouths,  work  as  sharp  and  perfect  can  be  done  with 
gutta-percha  as  with  plaster.  In  difiicult  cases  a 
rough  impression  should  first  be  taken,  and  such 
shaping  given  it  with  the  fingers,  after  removing 
it  from  the  mouth,  as  to  allow  of  its  being  easily 
introduced  a  second  time.  Then  let  it  be  cooled  until 
it  is  quite  hard.  A  thin  substance  of  quite  soft 
gutta-percha  is  then  placed  over  the  whole  surface, 
which  should  be  first  dried  with  a  napkin,  and  it  is 
again  inserted  in  the  mouth,  and  held  for  about  two 
minutes,  when  it  may  be  removed  and  cooled.  Care 
is  necessary  to  prevent   alteration  in   shape   from 


GUTTA-PERCHA    FOR    IMPRESSIONS.  195 

"  sucking  "  of  the  impression.  Pulling  an  impres- 
sion out  of  the  mouth  by  main  force  is  not  an  idea 
which  is  likely  to  occur  to  any  experienced  dentist, 
but  a  novice  might  easily  be  made  nervous  by  the 
adhesion  of  a  really  good  impression,  and  destroy 
it  by  pulHng  at  it,  when  a  lifting  of  the  lip  and 
cheek  high  enough  to  admit  the  air,  and  a  tipping 
of  the  tray  at  the  same  instant,  or  instructing  the 
patient  to  close  the  lips  firmly  around  the  handle  of 
the  tray,  and  by  a  sudden  expiration  to  fill  the 
mouth  with  air  from  the  lungs,  tipping  the  tray  at 
the  right  moment,  would  release  it  without  violence 
or  injury. 

Sometimes  an  impression  is  wanted  for  a  partial 
set,  when,  from  abnormal  length  of  the  remaining 
teeth,  it  is  difficult  to  find  a  well-adapted  tray; 
but  one  may  be  quickly  extemporized  by  partially 
filling  an  ordinary  tray,  and  obtaining  a  rough 
impression  of  the  parts  that  are  without  teeth,  then 
cooling  and  drying  this,  and  placing  more  warm 
gutta-percha  over  all,  and  introducing  it  a  second 
time. 

For  most  purposes  in  the  arts  gutta-percha  is 
largely  adulterated,  but  it  can  be  obtained  in  a  pure 
state  from  the  manufacturers  at  a  cost  of  about  nine 
or  ten  shillings  a  pound.  The  process  of  cleansing 
it,  and  freeing  it  from  the  impurities  that  are  acci- 
dentally and  intentionally  mingled  with  it  in  collect- 
ing and  preparing  it  for  a  market,  is  fully  described 
in  the  ninth  edition  of  the  Enajclopcedia  Britannica, 
and  some  interesting  statements  are  made  about  the 


196  DENTAL    PRACTICE. 

various  uses  to  which  it  is  applied.     I  make  a  few 
extracts  from  this  work. 

"  The  readiness  with  which  gutta-percha,  whilst 
in  its  plastic  condition,  receives  an  impression  which  it 
retains  when  cold,  early  led  to  its  employment  in  the 
decorative  and  fine  arts,  since  it  reproduces  the  finest 
lines,  as  in  the  taking  of  moulds  from  electrotypes." 

I  have  italicized  the  portions  of  the  text  which 
refer  to  qualities  I  have  mentioned  as  peculiarly 
fitting  this  valuable  product  for  dental  purposes. 
The  same  authority  says,  "  Gutta-percha  is  resolv- 
able into  two  resins — albin  and  fluavil.  Like  caout- 
chouc, or  india-rubber,  it  is  a  hydrocarbon.  Soubeiran 
gives  its  composition  as  carbon  87-80  and  hydrogen 
12'20.  In  commercial  gutta-percha  we  have  this 
hydrocarbon,  or  pure  gutta,  plus  a  soft  resin,  a 
resultant  of  oxidation  of  the  hydrocarbon. 

M.  Payen  gives  the  following  analysis  of  com- 
mercial gutta-percha:--"!  Crystalbin,  or  albin 
(O^o  Hg^  OJ,  white,  and  crystallising  out  of  the 
alcohol  as  it  cools,  6  to  14  per  cent.,  2  Fluavil 
(C^^  H32  OJ,  yellow,  falling  as  an  amorphous  powder 
on  the  cooling  of  the  alcohol,  6  to  14  per  cent.  It 
is  thus  apparent  that  the  change  of  pure  gutta  into 
a  resin-like  mass  takes  place  naturally,  if  means  be 
not  taken  to  stop  it.  Many  a  good  parcel  has  been 
thus  lost  to  commerce,  and  the  only  remedy  seems 
to  be  thorough  boiling  as  soon  after  collecting  as 
possible." 

It  is  this  tendency  to  degenerate  into  a  resinous 
mass  that   so   soon  spoils  gutta-percha  -  for  taking 


GUTTA-PERCHA    FOR    IMPRESSIONS.  197 

impressions,  if  it  is  not  kept  in  water ;  for  it  soon 
becomes  too  sticky  for  either  comfort  in  manipula- 
tion or  accuracy  in  practice  ;  and  it  is  no  doubt 
this  rapid  faiUng  in  efficiency  that  has  caused  it  to 
be  so  generally  given  up  by  the  dentists  as  a 
material  for  this  purpose.  But  it  may  be  kept  in 
water  for  a  reasonable  time  without  any  apparent 
deterioration,  though  if  it  is  overheated  when  being 
prepared  for  use,  it  will  soon  become  sticky  and 
unpleasant. 

The  Enciiclopcedia  says  further:— "At  a  tempera- 
ture of  32°  to  77°  Fahr.,  gutta-percha  has  as  much 
tenacity  as  thick  leather,  though  inelastic  and  less 
flexible.  In  water  at  110°  Fahr.,  it  becomes  less 
hard;  towards  120°  Fahr.  it  becomes  doughy, 
though  still  tough ;  and  at  from  145°  to  150°  it 
grows  soft  and  pliable,  allowing  readily  of  being 
rolled  and  moulded.  In  this  state  it  has  all  the 
elasticity  of  caoutchmc,  but  this  it  loses  as  it  cools, 
gradually  becoming  hard  and  rigid  again,  and 
retaining  any  form  impressed  on  it  whilst  in  its  plastic 
condition." 


199 


INDEX 


Absurd  practice,  5. 
Arsenic — preparation   of,    for  devi- 
talization of  pulps,  12. 
Method  of  using,   13. 
Danger  from,  13. 
Clumsiness  in  use  of,  14 
Absorption  of  roots,  16. 
Absorbent  organ,  17. 
Attempt  to  correct  deformity  from 

tongue -sucking,  23. 
Amadou  for  drying  cavities,  51. 
Advantages     of     gutta-percha     for 

filling  young  teeth,  52. 
Approximal  decay  in  incisors,  47. 
,  »       bicuspids.  56 

,  ,       canines,  57. 

Anaesthesia,  advantages  of,  70. 
Surgical  attendance  for,  73 
Minimum  of  danger  from,  78. 
Attrition,  loss  of  substance  from, 167. 
Amalgam,  169. 

Arthur,  Dr.  Robert,  a   method  of 
treatment,  56. 
Extract  from  letter  to,  188. 
Antagonizing  teeth,  the  extraction 

of,  60. 
Bacteria  in  putrescent  pulps,  18. 
Bicuspids,  approximal  decay  in,  56. 
Backward  movement  of,  62. 
Restoring  palatine  cusp  of,  with 

gold.  148. 
Restoring   buccal   cusp   of,  with 
porcelain,  189. 
Building  up  the  crown  of  a  molar 
tooth,  172. 


Completion  of  first  dentition,  2. 

Cleanliness,  2. 

Of  pulpless  teeth,  11. 
In  regulating  cases,  89. 

Cruelty  of  premature  extraction,  9. 

Causes  of  toothache,  10. 

Cutting  away  decay,  50,  56,  66. 

Carbolic  acid,  19,  34,  51,  89,  101, 
164. 

Comparative  value  of  gold  and  gutta- 
percha for  filling  teeth  before 
puberty,  28. 

Cessation  of  development  from 
death  of  pulp,  38. 

Canine  teeth,  approximal  decay  in, 
57. 

Careful  study  of  the  teeth,  59. 

Causes  of  early  decay  in  wisdom 
teeth,  68. 

Chloroform,  74. 

Cohesive  gold,  129. 

Cei'vical  caries,  153. 

Careful  work  with  gutta-percha,  155. 

Comparative  durability  of  gold  and 
gutta-percha  in  cervical  cavi- 
ties, 157. 

Composite  fillings,  171. 

Diagnosis  of  toothache,  10. 

Devitalization  of  pulps,  12. 

Dental  subjects,  popular  knowledge 
on,  26. 

Dead  pulps  in  roots  not  fully 
developed,  38. 

Defective  teaching,  41. 

Development  of  wisdom  teeth,  (Hi. 


200 


INDEX. 


Decay  during  gestation,  144. 
Effect  on  the  minds  of  children  of 
injudicious    talk    on    dental 
subjects,  4. 
Early  decay,  4. 

Essig,  Dr.   Charles,   a  method    of 
making  and  fitting  gold  caps 
on  gutta-percha  fillings,  30. 
Erroneous  use  of  term  "  dead  tooth," 

36. 
Extraction  of  temporary  incisors,  38. 
Of  permanent  molars,  61. 
The  proper  time  for,  78. 
Not  a  certain  means  of  preventing 

decay,  80. 
Arguments  against,  82. 
Instruments  for,  71. 
Early  approximal  decay,  46,  56,  57. 
Ether,  74. 

Ethidene  dichloride,  76. 
Enamel  chisels,  122. 
Excavators  and  pluggers,  123. 
Effect  of  severe  brushing,  153. 
Erosion,  158. 

Case  in  practice,  159. 
Another  form  of,  163. 
Case  in  practice,  163. 
Effect  of  acid  secretions  in  illness, 

161. 
Fear  of  the  dentist,  3,  9,  143. 
First  permanent  molars,  25. 

Early  decay  in,  25. 
Filling  roots,  various  methods  of,  34. 
Failure  of  fillings  in  sensitive  cavi- 
ties, 115. 
Facility  of  cleansing  treated  sur- 
faces, 126. 
Fixing  artificial  crowns,  182. 

Case  in  practice,  187. 
Gold  fillings  in  temporary  teeth  an 

absurdity,  5. 
Gaining  the  confidence  of  a  child, 9. 
Gutta-percha  for  filling  teeth,  5,  27, 
51,  81,  143,  155. 


Gold  caps  for  gutta-percha  fillings, 

29. 
Gold  fillings  in  permanent  teeth, 

117. 
Gold  foil,  soft,  127.  ' 

Cohesive,  129. 
Grinding  surface  cavities,  149. 
Gutta-percha   safer  than    gold    in 

obscure  positions,  153. 
Gutta-percha    for    taking    impres- 
sions, 192. 
Preparation  of,  193. 
Home   examinations  of    children's 

teeth,  3. 
Heterodox  treatment,  15. 
Home  encouragement  in  regulating 

cases,  43,  88. 
Inflammation  of  the  pulp,  12,  33. 
Irregularity  of  the  temporary  teeth, 

20. 
Irregularities  which  require   early 

treatment,  42. 
Irregularities  which  are  best  treated 
about  the  twelfth  year,  87. 
Cases  in  practice,  90,  93,  96,  102, 
107. 
Imperfect  enamel,  53. 
Important  use  of  the  wisdom  teeth, 

69. 
Instruments  for  extracting,  71. 

For  gold  fillings,  123. 
Jack-screws,  109. 

Lengthening    of   maxillary    bones 
dependent    on    development 
of  molar  teeth,  8. 
Lower  central  incisors,  38. 
Lower  teeth   shutting  against  the 

hard  palate,  94. 
Letter  to  Dr.  Arthur,  extract  from, 

138. 
Liberal  and  eclectic  ideas,  142, 
Lining  cavities  with  gutta-percha, 

145,  171. 
Loss  of  substance  from  attrition,  167 . 


IKDEX. 


201 


Method  of  using  arsenic,  13. 

Malpractice,  27, 

Minimum  of  danger  from  anaesthe- 
sia, 78. 

Metal  fillings  not  fit  for  sensitive 
teeth,  115. 

Mouth  mirror,  48,  49,  110. 

Modern  operating  appliances,  131. 

Mallet,  135. 

In  grinding  surface  cavities,  151. 

Mistaken  teaching,  141. 

Medicine,   efi"ect   of  on    the   teeth, 
IGl. 

Nurses  teaching  children  to   suck 
the  thumb,  23. 

Natural  separation  of  the  teeth  after 
extraction  of  the  molars,  62. 

Nitrous  oxide,  76. 

Necessity  of  retaining-plates  in  some 
cases  of  regulating,  45. 

Nature's  method  of  protecting  the 
nerve,  165. 

Nodules  or  pulp  stones,  16(). 

Popular  knowledge,  4,  26. 

Professional  discretion,  4. 

Prevention  of  pain  by  timely  opera- 
tions, 4. 

Premature  extraction,    contraction 
from,  5. 
Cruelty  of,  9. 

Preparation  of  arsenic  for  devitali- 
zation of  pulps,  12. 

Preparation  of  cavities  for  filling. 
48,  124. 

Preparation  of  a  grinding  surface 
cavity,  150. 

Preparation  of  materials  for  plastic 
fillings,  175. 

Preparation  of  roots   for  pivoting, 
181. 

Preparation     of    gutta-percha    foi 
taking  impressions,  193. 

Primary  toothache,  10,  33. 

Putrescent  pulps,  18,  37. 


Permanent  teeth,  early  decay  in,  25. 

Parental  anxietj%  38. 

Preparing   cavities   in   front  teeth, 

124. 
Pressure  of  wisdom  teeth,  79. 
Permanent  bicuspids  and  canines, 

56,  57. 
Projecting  upper  teeth  with  lower 

teeth  shutting    against    the 

hard  palate,  94. 
Cases  treated,  96,  102. 
Permanent  fillings,  115 
Periostitis  after  a  prolonged   oper- 
ation, 132. 
Case  in  practice,  132. 
Perfection  by  easy  stages,  143. 
Professional  jealousy,  144. 
Packing  tin  and  gold  fillings,  145. 
Gutta-percha    and  gold    fillings 

147. 
Case  in  practice,  147. 
Prejudice  against  amalgam,  109. 
Quick  observation  while  operating, 

125. 
Retention  of  temporary  teeth,  1. 
Regulating  cases,  42,  44,  90,  93,  96, 

102,  107. 
Retaining-plates,  45, 105. 
Rubber  dam,  134. 
Restoring  one  cusp  of  a  bicuspid, 

147,  191. 
Simple  fillings,  5. 
Secondary  toothache,  15,  37. 
Sucking  the  thumb,  21. 
The  fingers,  22. 
The  tongue,  23. 
Self-cleansing  surfaces,  126. 
Surgical  assistance  in  anaisthesia, 

73. 
Screws  and   springs   in  regulating 

cases.  111. 
Swollen  gums,  102. 
Senseless  treatment,  103. 
Shaping  cavities,  124 


202 


INDEX. 


Soft  gold  fillings,  127. 

Soft  and   cohesive   gold  fillings, 
129. 
Saliva  ejector,  134. 
Supposed  effect  of  medicine  on  the 

teeth,  161. 
Temporary  teeth,  retention  of,  1. 
Simple  fillings  in,  5. 
Contraction  from  premature  ex- 
traction of,  5. 
Irregularity  of,  20. 
Teeth  brushing,  3. 
Displacement    of   by  premature 
extraction,  6. 
Toothache,  primary,  10,  33. 
Secondary,  15,  37. 
Causes  of,  10. 
Diagnosis  of,  11. 
In  six  year  molars,  33. 
Treatment  of  periostitis,  37. 

After  devitalization  of  the  pulp, 

19,  35. 
For    congestion    of    peri-dental 

membrane,  11. 
Of  imperfect  enamel,  55. 
Temptation  for  young  practitioners, 
41. 


Turning  a  front  tooth,  44. 
Twelve  year  molars,  58. 
Timid  treatment,  69. 
Tooth  extracting  as  a  specialty,  7  7. 
Time  for  extractions,  78. 
Teeth  affected  in  pairs,  84. 
Teeth  elongated  by  backward  pres- 
sure, 104. 
Toleration  of  Jack-screws,  109. 
Treatment  of  adult  teeth,  114. 
Time  spent  in  operations,  132. 
Tongue  depressor,  134. 
Tin  and  gold  fillings,  145. 
Treatment  of  teeth  after  illness,  161. 

For  nodules,  167. 
Taking  impressions,  192. 
Under-hung  jaws,  22. 
Upper  and  lower  lateral  incisors,  46. 
Uses  of  the  mirror,  49,  119. 
Unprofessional  practice,  118. 
Widening  upper  jaw,  168. 

Case  in  practice,  168. 
Wedging  teeth  apart,  136. 

Case  showing  effect  of  this  treat- 
ment, 139. 


LIVERPOOL : 

GILBERT  G.  WALMSLEY,  PRINTEK, 
LOUD   STREET. 


RK53 

Quinby 

Notes  on  dental  practice 


Qu4 


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